| Field title |
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| Name of Company |
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| Donation Point of Contact Name |
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| Phone |
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| email |
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| Type of Commodity |
PPE |
Medical |
Engineer Svcs |
Industrial |
Food/Meals/Sustainment |
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Name of Product |
Name of Product |
Name of Product |
Name of Product |
Name of Product |
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SKU # |
SKU # |
SKU # |
SKU # |
SKU # |
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Model |
Model |
Model |
Model |
Model |
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Qty Available Now |
Qty Available Now |
Qty Available Now |
Qty Available Now |
Qty Available Now |
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Manufacturer Name |
Manufacturer Name |
Manufacturer Name |
Manufacturer Name |
Manufacturer Name |
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Manufacturer Address |
Manufacturer Address |
Manufacturer Address |
Manufacturer Address |
Manufacturer Address |
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Location of Supply |
Location of Supply |
Location of Supply |
Location of Supply |
Location of Supply |
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Industrial |
Swabs |
Construction Design |
Plastic Sheets |
Water |
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Medical |
Test Kits |
General Contracting |
Building materials |
Contained meals |
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Gloves |
Laboratory Svc |
Tents/ Camp |
Cots |
Shelf Stable Goods |
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Aprils |
Medical Gas |
Other - describe below |
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Face Shield |
Medical Professionals |
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Mask/Respirator |
Respirator |
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Protective Suits |
Tyvek Suits |
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Ventilators - describe below |
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| DONATION? |
Y/N |
N= Provide Billing and Procument Data Below |
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| Are you registered at "doing business.gov" or GSA Schedule |
Y/N |
GSA Schedule |
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| Location of Supply/Svcs |
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| Address |
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| Phone Number |
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| Shipping/ Booking POC |
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| Billing Address for sales |
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| Commodity Details |
Quantity |
Unit of Measure |
Total Each Count |
On Hand Now |
Production Estimate (Qty) |
Production Estimate (date) |
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ea/ Bottle |
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Xxxxx |
by XX April 2020 |
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box |
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case |
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Drum |
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| Is cargo HAZMAT? |
Y/N |
Yes = Provide Shipment HAZMAT Category |
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| Do you have transportation booking |
Y/N |
Yes = Provide Shipment Tracking Number and Carrier: |
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Shipping Dimensions |
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Ht |
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Lngth |
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Wdth |
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Weight |
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| Descriptions of Commodity/ Service |
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| FREE TEXT 500 Characters |
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| Other Comments or description |
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| FREE TEXT 500 Characters- with ability to upload picture of product |
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