ESSENTIAL SMALL BUSINESS MASK REQUEST FORM

ROCK GOV – FACE COV PROGRAM REQUEST FORM

This program is for businesses and nonprofits located within Rockland County with 20 employees or fewer. Please submit one (1) request per company; additional requests will not be fulfilled.
Face masks will only be available to the first 100 respondents who submit an online request.
Businesses who previously applied for face masks under the first round are NOT eligible to apply for the second round.
Face mask distribution is for ONE DAY ONLY. If you do not pick up your face masks on the date of distribution, you will forfeit your opportunity to receive them.

Business Name*

Address*

Street Address

Street Address Line 2

City/Town

Zip Code

Owner / Representative Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Number of Employees*

Confirmation*

I attest that I represent the business listed on this form in Rockland County with 20 employees or less in need of masks.

Due to the overwhelming success and response to the “ROCK GOV – FACE COV” Program, PPE requests have been suspended.

We understand the continued need for PPE in Rockland, and we will announce additional options in the near future.