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

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* 2. Website Address

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

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* 4. Do you currently do business with LA County?

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* 5. Have you previously done business with LA County?

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* 6. If you have a County Vendor Number, please enter it here

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

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* 8. If you answered yes to the question above, please describe.

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* 9. Does your organization hold any government
issued credentials, licenses or similar?

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

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

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* 13. Product Manufacturer Name:

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* 14. Manufacturer Part Number

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

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* 16. What is the price per unit?

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* 17. What is the earliest date you could deliver the units?

Date

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* 18. Attach a specification form

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

T