Donation Survey

Overview: If you are an organization interested in donating supplies, services, and/or equipment to New Mexico's communities in need, please complete the survey below.

Question Title

* 1. Point of Contact

First / Last Name

Organization Name

Job Title

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. We are capable of donating supplies and/or equipment in the following cateories. Please enter the amount of items you have available for donation in each category. If you do not have supply available for a particular category simply enter "0".

Note: Any additional detail related to items may be noted in the Comments/Notes field or uploaded through the Attachment field.

N-95 Masks

Surgical Masks

Isolation Gowns

Hand Sanitizer (in ounces or gallons)

Face Shields

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* 3. Please use the space below to enter other supplies, materials, and/or equipment that are not listed above. Please list the names and quantities of the items you can donate.

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* 4. We have the ability to ship and/or transport the supplies/equipment from our facility to an NM community in need.

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* 5. The supplies, services and/or equipment will be available on the following date:

Date

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* 6. Comments/Notes: (please consider using this space or the Attachment field below to provide any specific information that would help us better understand your needs, include quantities, sizes, specifications)

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* 7. Attachments - Use the file upload button below to provide further information related to your response.

File size limit is 16MB (Only PDF, DOC, DOCX, PNG, JPG, JPEG, GIF files are supported)

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

Choose File