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Hand Sanitzier Sign Up Form

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  2. HAND SANITIZER DISTRIBUTION (1)
  4. Utilizing funds from the CARES Act, the City of Berea has purchased a limited quantity of one-gallon containers of hand sanitizer from Western Reserve Distillers in Lakewood. The City is offering these one-gallon containers of hand sanitizer to businesses and non-profits located in the City of Berea at no cost. There is a limit of one container per business or non-profit and the City of Berea will deliver the container to your business address in Berea.
  6. There is a limited supply of hand sanitizer which will be distributed on a first come, first served basis.
    If you are interested in receiving hand sanitizer, please complete this online form. This online form is the only method to request hand sanitizer. Requests for hand sanitizer submitted through email, social media, telephone, regular mail or any other method will not be accepted.
  8. PLEASE NOTE: There is no option for you to pick up the hand sanitizer. We will deliver it to you.
  12. This is the address where the hand sanitizer will be deliver. This must be an address within the City of Berea
  22. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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  27. This field is not part of the form submission.