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COVID-19 Mask Request

2. Mask Request Form
   This form is for residents or businesses in the City of Green to request a homemade mask. These masks will only be distributed when available and priority will go to those who need them most. Masks are for Green residents and businesses only.

   This form is for residents or businesses in the City of Green to request a homemade mask. These masks will only be distributed when available and priority will go to those who need them most. Masks are for Green residents and businesses only.

4. I am requesting for*

   1. An Individual
   2. A Business

5. How many masks are you requesting?*

7. Are you employed in the healthcare field?*

   1. Yes
   2. No

9. Business Name*

11. First Name*

12. Last Name*

14. Home or Business Address*

16. Phone Number*

17. Email Address

19. Are you 65 or older or is someone in your house immunocompromised?*

    1. Yes
    2. No

21. Additional Information

Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field