Critical Equipment

Request Form

If you or someone you know works for an organization on the frontlines of COVID-19, complete this form to submit a request.

By filling out this form, you agree to allow PPE IMPEX to disclose the information you provide to PPE IMPEX, consistent with PPE IMPEX’s mission to connect personal protective equipment (PPE) suppliers to those who need it most–the healthcare providers at the frontline.

First Name *

Last Name *

Country *

Are you a ? * Are you a ? * Individual Buyer Organization/ Company

What do you want to use PPE products for ? *

Your Email Address *

Name of Organization/ Company *

Website of the Organization/ Company (If applicable)

Organization/ Company Street Address *

City *

State/ Province *

Postal Code *

What products are you looking to procure? Type all the PPE products down below. Separate products by a comma. Ex :- Disposable Surgical Masks, Nitrile Gloves *

Type the certifications required for the above items. (If applicable ) Ex:- CE Certificate, FDA Certificate

Are you able to pay upfront for the above requested PPE products? * (Most suppliers are requiring deposits and or prepayment terms and conditions before delivery *) Are you able to pay upfront for the above requested PPE products? * (Most suppliers are requiring deposits and or prepayment terms and conditions before delivery *) Yes No

I confirm above details I provided are accurate & correct * I confirm above details I provided are accurate & correct * I confirm

What products are you looking to procure? Type all the PPE products down below. Separate products by a comma. Ex :- Disposable Surgical Masks, Nitrile Gloves *

Type the certifications required for the above items. (If applicable ) Ex:- CE Certificate, FDA Certificate

Are you able to pay upfront for the above requested PPE products? * (Most suppliers are requiring deposits and or prepayment terms and conditions before delivery *) Are you able to pay upfront for the above requested PPE products? * (Most suppliers are requiring deposits and or prepayment terms and conditions before delivery *) Yes No

I confirm above details I provided are accurate & correct * I confirm above details I provided are accurate & correct * I confirm