PPE Request Form

Supplies are running low. We will do our best to fill your order - you may not receive the total quantities requested.

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Personal Protection Equipment Request Form

The Wyoming County Office of Emergency Management has a provided a limited amount of free cloth masks, gloves (latex), and hand sanitizer available for businesses to request on a first-come, first-serve basis and as supplies last.

Please fill out the form below and click the submit button. You will be notified by email when and where the supplies will be available for pick-up.

Firstname *

Lastname *

Business Name *

Address *

City *

State *

Zipcode *

Phone *

Email *

Security Check *

Please indicate items needed and desired quantities below.

Cloth Masks (5 per pack)

Quantity requested

Latex Gloves (100/box)

Quantity requested

Please indicate preferred glove size

Hand Sanitizer - 2 ounce bottle

Enter Quantity Requested

Hand Sanitizer - 1 Gallon bottle

Enter Quantity Requested

Additional Comments or Questions

Security Check *