Face Shield Donation Request Form

I have produced over 100 face shields and I am arranging to produce thousands more.

These are being provided for free [donations will be accepted], with no guarantees implied or expressed. Use at your own risk. By accepting the donation you are releasing me of all liability.

Please complete the form below

Name

First Name

Last Name

Hospital/Institution/Business

The place or people who need face shields.

Shipping Address

This doesn't have to be the facility itself. I've heard from many people that due to logistics, it's going to be easier to get them to staff directly at their homes.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Requested Range

Please provide a range of the quantity desired. Minimum to get by to the maximum in an ideal world.

Can you cover any material or shipping costs?

I am trying to donate as many as possible, but if you can afford to pay, that helps cover the cost of other face shields.

Yes

Anything else?