Constituent PPE Request Form

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Constituent PPE Request Form

Please fill out this form if you would like to pick up some PPE from our office. Constituent pick ups will be Mondays and Fridays from 2 PM to 5 PM at 1077 Nostrand Avenue (Between Lefferts Avenue & Lincoln Road). Please note that supplies are limited.

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Email *

Your email

First Name *

Your answer

Last Name *

Your answer

Address *

Your answer

I would to get *

Hand Sanitizer

Face Covering

Mask

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