Mask Intake Form

Mask Distribution Form

Complete the registration below to receive face masks. Each registrant must arrange for pick-up of masks. Mask can only be picked up on Fridays between 10:00am – 2:00pm at 1408 N. Kingshighway Blvd St. Louis, MO 63113. Please see the guide on How to Wear Face Masks as recommended by Center for Disease Control.

* Indicates required field

Company or Organization *

Name *

First

Last

Main Number *

Secondary Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you a member of the Federation of Block Units? *

Yes No

Block Unit Number (if applicable): *

Comment *

Number of Mask

Mask Quantity *

Please allow up to one (1) week for your order to be ready and where to pickup. You will be notified when your order is ready. If you have any questions, please call 314-626-9977.

I agree to receiving marketing and promotional materials

Submit