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1
Your Product Needs
2
Contact Information
Face Shield Demand:
Anticipated Quantity
*
Please choose...
less than 50
50 to 100
100 to 500
500 to 1,000
1,000 to 10,000
more than 10,000
Checkboxes
*
FS-R: Reusable & Cleanable
FS-D: Disposable (Single Use)
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How often?
*
Weekly
Monthly
One Time Purchase
Customer / Facility Type
Health Care / Emergency Management
Private Business
K-12 School
College/University
Political Campaign
Personal Use
Other
Do you have the ability to sterilize the plastic shield for multiple uses?
*
Please choose...
Yes
No
Unsure / Other
Next
Contact Details:
Purchasing Contact
*
First
Last
Company / Institution
*
Primary Phone: *
Primary Phone
*
Primary Phone Type
*
Work
Mobile
Other
Secondary Phone:
Secondary Phone
Primary Phone Type (copy)
Work
Mobile
Other
Email: *
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