Personal Protective Equipment Request Form

Please complete and submit this form to request Personal Protective Equipment for your hospital. All requests will be reviewed as quickly as possible.

Please Note: All fields are required. Please submit this form using the latest versions of Microsoft Edge, Chrome, Firefox and Safari browsers.

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Name of Hospital

Address

City

State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP Code

Taxpayer Identification Number (TIN)

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First Name

Last Name

Job Title

Email

Phone

Nearest Harbor Freight Store Number

To find the Store Number of the Harbor Freight store near you, please use the Store Locator.

Find your preferred location and provide the number that appears on the first line.

Learn more about available Personal Protective Equipment:

• N95 Mask Specifications
• Face Shield Specifications
• 5 Mil Gloves Specifications
• 7 Mil Gloves Specifications

Please correct the highlighted fields above to continue.

Submit