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.

Question Title

* 1. Contact Information

Name *

Company *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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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.

Yes

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

Yes

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

Yes

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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?

Yes

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

Question Title

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

Yes

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

Question Title

* 1. Contact Information

Question Title

* 2. Website Address

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 11. Type of Personal Protective Equipment

Question Title

* 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?

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* 18. Attach a specification form

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

Question Title

* 1. Contact Information

Question Title

* 2. Website Address

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 10. If your organization holds any governmentissued credentials, licenses or similar, pleasesummarize here.

Question Title

* 11. Type of Personal Protective Equipment

Question Title

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

Question Title

* 13. Product Manufacturer Name:

Question Title

* 14. Manufacturer Part Number

Question Title

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

Question Title

* 16. What is the price per unit?

Question Title

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

Question Title

* 18. Attach a specification form

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

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

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