GW Safety and Preparedness Resources Request Form

Please fill out and submit this form to request for safety and preparedness resources for yourself or organization. Your request will be completed within five business days.

Name *

Email Address *

Phone Number

Division/Department/Office/Organization *

Materials Requested *

	0	5	10	25	50	100
Emergency Response Handbook *	Emergency Response Handbook - 0	Emergency Response Handbook - 5	Emergency Response Handbook - 10	Emergency Response Handbook - 25	Emergency Response Handbook - 50	Emergency Response Handbook - 100
Emergency Preparedness Pocket Guide *	Emergency Preparedness Pocket Guide - 0	Emergency Preparedness Pocket Guide - 5	Emergency Preparedness Pocket Guide - 10	Emergency Preparedness Pocket Guide - 25	Emergency Preparedness Pocket Guide - 50	Emergency Preparedness Pocket Guide - 100
ReadyGW Pen *	ReadyGW Pen - 0	ReadyGW Pen - 5	ReadyGW Pen - 10	ReadyGW Pen - 25	ReadyGW Pen - 50	ReadyGW Pen - 100
ReadyGW Magnet *	ReadyGW Magnet - 0	ReadyGW Magnet - 5	ReadyGW Magnet - 10	ReadyGW Magnet - 25	ReadyGW Magnet - 50	ReadyGW Magnet - 100
Emergency Kit Bag (empty clear plastic) *	Emergency Kit Bag (empty clear plastic) - 0	Emergency Kit Bag (empty clear plastic) - 5	Emergency Kit Bag (empty clear plastic) - 10	Emergency Kit Bag (empty clear plastic) - 25	Emergency Kit Bag (empty clear plastic) - 50	Emergency Kit Bag (empty clear plastic) - 100

Please select the amount of each item you need. For requests over 100, please contact our office directly (202-994-4983)

How will these materials be used? (If it is for a specific event, please provide the name.) *

When do you need this by? *

Month

Day

Year