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FREE MASK(S) FOR HOMELESS, LOW INCOMES, & VETERANS
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FREE MASK(S) FOR HOMELESS, LOW INCOMES, & VETERANS
Orpe Human Rights Advocates is currently serving only the States of Maryland, DC, & Virginia.
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Providing free masks as our response to COVID-19
Please note that you are responsible for shipping fee of $4.00 (up to 6 masks). Your order will be served on first come, first served basis. In case of unavailability of the product, the organization will refund the shipping cost of $4.00 paid.
Name of household
*
First
Last
Name of spouse
First
Last
Name(s) of child/children
Please provide the names of persons who need the masks.
Name
First
Last
Name
First
Last
Name
First
Last
Name
First
Last
Name
First
Last
Name
First
Last
Address
*
Address Line 1
Address Line 2
City
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Delaware
District of Columbia
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Texas
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
How many kids do you have?
*
None
1-2
3-6
How many masks do you need?
*
choose
1
2
3
4
5
6
Please send a proof of hardship.
*
Click or drag files to this area to upload.
You can upload up to 10 files.
Please send any proof that justify your state of hardship: for e.g. food stamp, TCA,... Note that each child included in this application must be justified by a proof of relationship with the applicant.
Email
*
Facemasks shipping fee
*
Price:
$ 4.00
eSignature
*
Clear Signature
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