COVID-19 Products & Services Offer Form

Form Closes: Friday, April 10, 2020

The purpose of this form is to collect information on businesses interested in selling or donating products and/or services to Miami-Dade County healthcare establishments impacted by exponential demand and supply chain shortages driven by COVID-19.

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* 1. Business Name:

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* 2. Contact Name & Title:

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* 3. Business Address:

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* 4. Phone:

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* 5. Email:

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* 6. Organization size:

1-10

11-50

51-100

101-500

500+

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* 7. Business Type:

Manufacturer

Distributer

Other (please specify)

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* 8. Donating or selling?

Donating

Selling

Both

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* 9. Good or service offered:

Face Shields

Freight Forwarding

Gloves

Gowns

Hand Sanitizer

Masks

Medical Equipment

Medical Support/Research

Technology Products or Services

Transportation Services

Warehouse Space

Other (please specify)

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* 10. Please provide a detailed description of products or services to be sold/donated:

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* 11. Do you have any certifications related to the products or services being offered?

If Yes, please describe the certification:

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* 12. If manufacturing a product, please share City, County, and State or Country the product will be manufactured in:

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* 13. Please provide a detailed description including the quantity of product or services you can produce (if relevant), pricing, timing, and any specific organizations or entities you are seeking to contract with:

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* 14. Please state current product and service availability and approximate arrival time:

By submitting this form you grant the Miami-Dade Beacon Council and The Beacon Council Economic Development Foundation (collectively, the “Beacon Council”) the right to collect and share the information provided in this form, including any personal information you provide, with prospective parties interested in procuring your goods and/or services. By submitting this form you agree that such prospective parties may contact you at the contact information you provide. The Beacon Council is serving as a conduit of information only and makes no representation, warranty, or guarantee of any kind regarding, and assumes no responsibility for, any of the goods or services described or information provided in this form. Neither the Beacon Council nor any of its directors, officers, or employees shall be held liable for any use or misuse of such goods or services or such information. The Beacon Council does not endorse or recommend any of the goods or services described or information provided in this form. Any questions about the process of collecting and sharing this data should be directed to BeaconHelp@beaconcouncil.com.