PPE Request Form

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Personal Protection Equipment Request Form

The Wyoming County Office of Emergency Management has a limited amount of free cloth masks, disposable procedural masks, gloves (nitrile and latex), face shields, thermometers, 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

Disposable Procedural Masks (50/box)

Quantity requested

Nitrile Gloves (100/box)

Quantity requested

Please indicate preferred glove size

Latex Gloves (100/box)

Quantity requested

Please indicate preferred glove size

Infrared Thermometer

Very limited quantities exist. Only one per request. The business must be required to measure employee temperature to request thermometer.

Face Shields (Packaged Individually)

Quantity requested

Hand Sanitizer - 2 ounce bottle

Enter Quantity Requested

Hand Sanitizer - 1 Gallon bottle

Enter Quantity Requested

Additional Comments or Questions