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2. County of Nevada has no cost PPE available for all small businesses with 25 employees or less. To apply for hand sanitizer and masks, please complete one form per business. PPE is available while supplies last.
4. Email Address*
6. First Name*
7. Last Name*
9. Phone Number*
10. Cell Number*
12. Tell us about your business.
14. Business Name
16. Business Address Line 1*
18. Address Line 2
20. City*
21. State*
22. Zip Code*
24. Employer Identification Number (EIN)*
26. Let us know where you would like to pick up your PPE. *

    1. 8:30 am-5:00 pm | Monday-Friday | Nevada County Contractors Association |149 Crown Point Court, Suite A | Grass Valley, CA 95945
    2. 11:00 am-3:00 pm | Monday-Friday | Grass Valley Chambers of Commerce | 128 E Main St | Grass Valley, CA 95945
    3. 8:00 am to 8:00 pm | Monday-Friday | 9:00 AM to 7:00 PM Saturdays | ZAP Manufacturing | 12619 Charles Dr, Grass Valley, CA 95945
    4. 10:00 am-2:00 pm | Wednesday | Penn Valley Chamber of Commerce | 17422 Penn Valley Dr, Penn Valley, CA 95946
    5. 9:00 am-2:00 pm Tuesday-Friday, 11:00 am - 2:00 pm Saturday, Closed Sunday & Monday | Nevada City Chamber of Commerce | 132 Main St, Nevada City, CA 95959
28. How many employees do you have?*

    1. 1-5
    2. 6-10
    3. 11-15
    4. 16-20
    5. 21-25
30. Additional Notes
32. *IMPORTANT* BEFORE YOU SUBMIT
    Please leave this box checked to receive your confirmation email. The email will originate from noreply@civicplus.com. Print, or display this confirmation email when you pick up your PPE.
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field