City of Albuquerque (CABQ) PPE
Distribution Form
Please note: Your business must be registered and located within the Albuquerque city limits.
Business Name
*
Type of Business
*
Years in Business?
*
Name
*
Work Phone
*
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
1. Are you located in Albuquerque?
*
Yes
No
2. Are you a low or moderate income business owner?
*
Yes
No
3. Number of Employees as of March 1, 2020?
*
4. Current Number of Employees?
*
5. Industry Type?
*
6. Women Owned?
*
Yes
No
7. Minority Owned?
*
Yes
No
8. Veteran Owned?
*
Yes
No
9. I want a Personal Protection Equipment (PPE) box for my small business? (each box includes: 10 cloth masks, 100 disposable masks, 3 bottles of sanitizer and 3 bottles of disinfectant).
*
Yes
No
10. How many boxes of PPE are you requesting? (5 boxes maximum)
11. When additional supplies become available (Plexiglass Dividers, boxes of gloves and no touch thermometer) please contact me?
*
Yes
No
Distribution Location: WESST Enterprise Center
Boxes available to be picked up by appointment ONLY. Please hit the submit button and someone will contact you for additional details.
Submit
Should be Empty: