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County of Los Angeles Covid-19-related Donations Form
*
1.
Contact Information
(Required.)
Contact Name
Company Name
Telephone Number
Email Address
Website Address
Address
City
State
Zip
*
2.
Type of Donation (Select at least one)
(Required.)
Food
Transportation
Supplies
Storage/Facilities
Pick Up/Delivery Service
Volunteer(s)
PPE/Healthcare Equipment
Lodging
Communications/Media
Other (list below)
3.
Please describe the donation, including capacity:
4.
Can you transport the donation, if applicable?
Yes
No
5.
If the donation is offered in a language other than English, please list the language(s).
6.
Is the donation being offered for a cost?
Yes
No
7.
Please provide any details related to the cost of the donation, if applicable.
*
8.
Is the donation worth more than $10,000?
(Required.)
Yes
No
9.
What is the earliest date that you could provide the donation?
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Hour
Time
:
Minutes
AM/PM
-
AM
PM
10.
Please briefly describe your company/organization.
11.
Do you/your organization have experience providing disaster relief?
Yes
No
*
12.
Do you currently do business with Los Angeles County?
(Required.)
Yes
No
13.
If yes, please describe.
14.
Please provide your Los Angeles County Vendor Number, if applicable.
15.
Please provide any additional information regarding the donation that was not included above.
Thank you for your willingness to assist during this uncertain time. Someone will be in contact with you soon.
