Marie's Original Fromulas LLC
401 N Middletown Road
Building 205
Pearl River, NY 10965
GuardianShield@marieoriginals.com
marieoriginals.com
(845)501-7330
Guardian Shield Registration Form:
If you have any questions please reach out to GuardianShield@marieoriginals.com
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Agency Name
*
Position In your Agency
*
Number of service members
*
How many service members are in the unit requesting a donation?
What best describes your agency
*
Municipal Agency
Government Agency
Private Agency (Volunteer or For-Profit)
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The request must be placed from a district office level or lower, such as a park office, ranger's office, district office, etc. Requests can also be made by employees in these offices, on behalf of their branch. Eligible agencies include USDA, BLM and NPS district offices, as well as other state and local agencies.
Please select the option that matches your agency
*
Please Select
Park Office
Rangers Office
District Office
USDA
BLM
NPS District Offices
Other
Other
Please describe type of agency
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Government or Municipal Agency
Does your unit operate in an area with poison ivy, oak, or sumac?
*
Yes
No
Does your unit engaged in wildfire containment, fuel reduction or outdoor work that requires daily interaction with poisonous plants? These can include non-firefighting forestry operations
*
Yes
No
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Private Agency
Are you affiliated with a government or municipality?
*
Yes
No
Have you received a donation from Marie Originals this season?
*
Yes
No
Are you operating hand crews, fuel reduction teams, or logging crews?
*
Yes
No
Are you actively contracted to or fighting a wildfire in an area with poison ivy, oak ,or sumac?
*
Yes
No
Are you facing a funding or logistic constraint that reduce your ability to procure poison ivy/oak treatments, or have lost personnel due to poisonous plants?
*
Yes
No
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Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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