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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.
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