PPE Vendor Application Form

How to Use this Form

This form is designed for vendors offering Personal Protective Equipment (PPE) for sale to Iowa long-term care facilities, and who are interested in being considered for inclusion on IHCA's PPE Vendor webpage used by Iowa long-term care providers to locate PPE suppliers.

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name

First Last

Email

Phone

Company Website

Product Types Available

N95 respirators
Surgical or procedure masks
Exam gloves
Surgical gowns
Medical face shields
Goggles
Alcohol-based hand sanitizer
Other

If other, please describe product type

Product Description

Click the + sign to the right to add additional product type descriptions.

Product Type (N95 respirator, surgical mask, face shield, etc.)	Total Quantity Available	Minimum Order Quantity	Price Per Unit

Original Equipment Manufacturer (OEM) Company Name

OEM Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are your PPE supplies CDC or FDA approved?

Yes
No

Product Offering Availability

Permanently. Our company always offers PPE supplies for sale.
Temporary. We have a limited amount of PPE available while supplies last.

Are you an IHCA Associate Member? *

Yes
No

If no, are you interested in information on becoming an IHCA Associate Member?

Yes
No

Has your company completed a PPE order for an Iowa health care provider? *

Yes
No

Proof of doing business in Iowa

Upload any documentation demonstrating your fulfillment of a PPE order for an Iowa health care provider.

Drop files here or

PPE Vendor Application Form Instructions

How to Use this Form