Fillable BUSINESS INFORMATION The Village received a generous donation (Incorporated Village of Lindenhurst)

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BUSINESS INFORMATION The Village received a generous donation (Incorporated Village of Lindenhurst)

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The Village received a generous donation of PPE masks from Village resident Franklin Cruz. Masks will
be distributed to businesses located in the Village of Lindenhurst. If your business would like to receive
a box of 50 masks, free of charge, please fill out the below form in its entirety and submit it via email
to info@villageoflindenhurstny.gov.
BUSINESS INFORMATION
BUSINESS NAME: ___________________________________________________________________
BUSINESS ADDRESS: _________________________________________________________________
_________________________________________________________________
NUMBER OF EMPLOYEES: ________________ BUSINESS PHONE #: _______________________
BUSINESS EMAIL: ____________________________________________________________________
Is your business receiving PPE assistance from other groups? If yes, who? _____________________
CONTACT INFORMATION
REQUESTOR NAME: __________________________________________________________________
EMAIL: ____________________________________________________________________________
PHONE #: __________________________________________________________________________
If you have any questions about receiving masks, please contact Lindenhurst Village Hall at (631) 957-
7500 or by email at info@villageoflindenhurstny.gov.
MASK REQUEST FORM FOR BUSINESSES
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BUSINESS INFORMATION The Village received a generous donation (Incorporated Village of Lindenhurst)

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Completed 19 January 2021

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