The County is prioritizing the need for: (1) N95 Respirators, (2) Face Shields, (3) Surgical Gowns; (4) Gloves; and (5) Eye Protection. Please be advised that submitting information to this form is NOT a guarantee of an agreement. Thank you for your information. The County will proceed at its discretion in responding.

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1. Contact Information (Required.)

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2. Website Address (Required.)

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3. Would you like to donate these items to the County? If yes, go to this donation form. (Required.)

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4. Do you currently do business with LA County? (Required.)

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5. Have you previously done business with LA County? (Required.)

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6. If you have a County Vendor Number, please enter it here (Required.)

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7. Do you currently do business with US federal, state, and/or local businesses? (Required.)

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8. If you answered yes to the question above, please describe. (Required.)

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9. Does your organization hold any government
issued credentials, licenses or similar? (Required.)

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10. If your organization holds any government
issued credentials, licenses or similar, please
summarize here. (Required.)

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11. Type of Personal Protective Equipment (Required.)

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12. Product Description (e.g.,
common product / model name): (Required.)

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13. Product Manufacturer Name: (Required.)

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14. Manufacturer Part Number (Required.)

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15. How many units do you have in stock that you will make available to the County? (Required.)

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16. What is the price per unit? (Required.)

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17. What is the earliest date you could deliver the units? (Required.)

Date

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18. Attach a specification form (Required.)

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