COVID-19 Response Form

Contact Email*

Company/Distillery Name*

Company/Distillery Address*

Street Address Address Line 2 City State Zip/ Postal Code

Point of Contact*

First Last

Point of Contact Phone (OPTIONAL)

Who are you currently offering sanitizer to?*

Select All
First responders (police, EMTs, firefighters, etc.)
Medical (hospitals or doctors, nurses, etc.)
My community, as donation
My community, for sale
Other

If you answered other above, please explain who you're offering sanitizer to

Do you have everything you need to continue to produce and distribute hand sanitizer or do you need supplies or logistics support?*

If you answered NO above, please use the checkboxes below to let us know what supplies and/or logistics support you need.

What supplies do you need?

Ethanol
Hydrogen peroxide
Glycerine
Bottles / containers
Other

If you answered other above, please explain what other supplies you need.

What help with distribution do you need?

Transportation help
Delivery help - to a single location
Delivery help - to multiple locations
Drivers, trucks, or trailers
Warehouse storage or staff
Other

If you answered other above, please explain what other distribution or transportation support you need.

How is your hand sanitizer packaged?*

Individual containers
Commerical / bulk packaging

How much sanitizer are you able to produce weekly?

What groups are you interested in working with?

Providing donations to health and safety organizations
Other retailers (to sell)
Government entities
Other

If you answered other above, please explain what other groups you are willing or already working with.

May we publicly share your willingness to help?*

Yes, please publicly display my company or distillery

Distilleries or companies who are willing to help can opt to display their information, including location and contact information, on distilledspirits.org. You can also opt-out, and request that DISCUS contact your company privately.

Are you willing to be connected with others to share or sell your sanitizer?

Yes, please indicate that I'm looking to be connected

Distilleries or companies who are willing to help can specifically opt to be listed as looking to connect with community organizations, distributors, retailers, and anyone who needs or wants to purchase sanitizer. Don't want to be connected? No problem! Just leave this box un-checked.

COVID-19 Spirits Industry Resource Connection

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