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Resource Request Form

  1. i.e. number of employees, volunteers, etc.

  2. Primary Contact

  3. Request

  4. Enter a number >1 for additional lines below. Maximum 7.

  5. Please explain how the resources will be utilized.

  6. Priority:

  7. Are you a Health Care or Long-Term Care Facility?

  8. Have you requested resources from the Healthcare Coalition or SEOC?

  9. Have you exhausted all resources received from the Healthcare Coalition and the SEOC?

  10. Leave This Blank:

  11. This field is not part of the form submission.