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2. Submission Form
   Northampton’s Public Health Director, Merridith O’Leary, issued orders effective April 16, 2020, at 12:01 a.m., establishing that all consumers and employees wear face coverings at all times when social distancing can not be maintained, at any businesses providing essential services within the City of Northampton. The City and Cooley Dickinson Hospital have partnered to streamline collections, launder and package donations, and distribute. Residents, businesses, and public agencies in need of face masks can request them by filling out this form.
4. First Name*
5. Last Name*
7. Business Name
8. Contact Phone Number*
10. Delivery Address*
12. Delivery Address 2
14. City*
15. State
16. Zip
18. Quantity Requested*
    -- Select One --123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100
19. Email Address:
21. Delivery Instructions*
    Indicate drop-off, pick-up or mail and any other special instructions.
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23. 1. Receive an email copy of this form.
24. Email address

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