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PPE Order: August 2020

Please fill in quantity from the amount emailed to you.

Please be sure to complete address where we need to deliver.

Pricing includes tax and delivery.

Thank you

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Personal Information

Name (First, Last)
Email
Clinic Name
Street address
City

Payment

Hand Sanitizer (Case of 25) Quantity: Cost: $145.00
Masks (Case of 50) Quantity: Cost: $58.00
3M K95 (1) Quantity: Cost: $8.00
N95 (1) Quantity: Cost: $11.00
Face Shield (1) Quantity: Cost: $5.00
Gloves (100) Quantity: Cost: $13.00
Size for gloves 
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Credit Card Payment Information

(All credit card information must be filled out completely to make a payment.)
Amount:
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Card Number:
Name on Card:
Verification #:
Expiration Date: (MM/YYYY)
Billing Address:
City   State   Zip:
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APTA CT PO Box 459
Tolland, CT 06084
(857) 702-9915
ctapta@libertysquaregroup.com