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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.

Are you a ? *

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 *)

I confirm above details I provided are accurate & correct *

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 *)

I confirm above details I provided are accurate & correct *