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County of Los Angeles Covid19-related Personal Protective Equipment and Other Goods/Services Information Form

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.
1.Contact Information(Required.)
2.Website Address(Required.)
3.Would you like to donate these items to the County? If yes, go to this donation form.(Required.)
4.Do you currently do business with LA County?(Required.)
5.Have you previously done business with LA County?(Required.)
6.If you have a County Vendor Number, please enter it here(Required.)
7.Do you currently do business with US federal, state, and/or local businesses?(Required.)
8.If you answered yes to the question above, please describe.(Required.)
9.Does your organization hold any government
issued credentials, licenses or similar?(Required.)
10.If your organization holds any government
issued credentials, licenses or similar, please
summarize here.(Required.)
11.Type of Personal Protective Equipment(Required.)
12.Product Description (e.g.,
common product / model name):(Required.)
13.Product Manufacturer Name:(Required.)
14.Manufacturer Part Number(Required.)
15.How many units do you have in stock that you will make available to the County?(Required.)
16.What is the price per unit?(Required.)
17.What is the earliest date you could deliver the units?(Required.)
Date / Time
18.Attach a specification form(Required.)
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