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COVID-19 Response Form
COVID-19 Spirits Industry Resource Connection
The purpose of this form is to connect distillers with related industry suppliers to combat COVID-19.
Contact Email
*
Company/Distillery Name
*
Company/Distillery Address
*
Street Address
Address Line 2
City
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Maine
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Michigan
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New Hampshire
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New York
North Carolina
North Dakota
Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP 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?
*
Yes
No
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.
