Procurement Form

We are grateful for the support of Texas's coronavirus response efforts.

Please submit one product per form submission.

First Name

Last Name

Phone Number

Please us provide the number in the following format: +1 (999) 999 9999

Title

Role

Manufacturer Name

Manufacturer Location

Vendor Name

Vendor Address

Vendor Country

Vendor State

Vendor City

Vendor Zip

EIN Number

FDA Registration

FDA Product Registration

NIOSH Certificate

CE Product Registration

Proof Of Certifications

Provide a link with certifications for FDA, CE, and NIOSH. Brokers must also provide a written confirmation from the manufacturer confirming supply and delivery, as well as, an official quote on letterhead.

Product Type

If Other, please describe

Product Name

Product Specs

Product Address

Product Country

Product City

Product Zip

Quote For 500,000

Quote For 1 Million

Quote For 5 Million

Quote For 10 Million

Quanity Available Immediately

Quantity to be Produced with Estimated Production Schedule

Payment Terms

(i.e. deposit or prepayment requirements, payment schedule, if any)

Payment Method

(i.e. ACH, e-check, wire transfer, etc.)

Does Include Shipping

Estimated Shipping Date

Estimated Delivery Date

Other