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2. First Name*
3. Last Name*
5. Branch*
   -- Select One --AtkinsBelcher-WycheBlanchardBroadmoorCedar Grove/Line AvenueDavid RainesGilliamHamilton/South CaddoHigginbotham-BrysonHollywoodHosstonMeansMainMooretownMooringsportNorth CaddoNorth ShreveportOil CityRodessaWalletteWest Shreveport

   Please select your branch
7. Please select your items:

   1. Jumbo Toilet Tissue (8 rolls/case)
   2. Regular Toilet Tissue (96 rolls/case)
   3. Multi-Fold Paper Towels (4000/case)
   4. Pine Oil Concentrate Disinfectant Cleaner
   5. Toilet Bowl Disinfectant Cleaner (6 bottles/case)
   6. Pink Lotion Dispenser Soap
   7. "Comet"-Type Cleanser (24 per case)
   8. Air Freshener (12 per case)
   9. Disinfectant Spray - "Lysol" type Aerosol spray
   10. Furniture Polish (12 per case)
   11. Glass Cleaner (12 per case)

   1. Waxed Paper Sanitary Napkin Bag Liners
   2. Wypall Disposable Wipes (18 packs/case)
   3. Broom
   4. Mop Handle
   5. Mop Head
   6. Super Sorb Absorbent Powder (24 cans per case)
   7. Hand Sanitizing Gel Pumps
   8. Sanitizing Wipes
   9. Bleach
   10. 33-Gallon Trash Bags (200 bags/case)
   11. 60-Gallon Trash Bags (100 bags/case)
9. How many cases of Jumbo Toilet Tissue?
   -- Select One --12
10. How many cans of Glass Cleaner?
    -- Select One --234
12. How many cases of Regular Toilet Tissue?
    -- Select One --12
13. How many packs of Waxed Paper Sanitary Napkin Bag Liners?
    -- Select One --1
15. How many cases of Multi-Fold Paper Towels?
    -- Select One --12
16. How many cases of Wypall Disposable Wipes?
    -- Select One --12
18. How many bottles of Pine Oil Concentrate Disinfectant Cleaner?
    -- Select One --123
19. How many Brooms?
    -- Select One --1
21. How many cases of Toilet Bowl Disinfectant Cleaner?
    -- Select One --1
22. How many Mop Handles?
    -- Select One --1
24. How many packs of Pink Lotion Dispenser Soap?
    -- Select One --48
25. How many Mop Heads?
    -- Select One --1
27. How many cans of "Comet"-Type Cleanser?
    -- Select One --23
28. How many cans of Super Sorb Absorbent Powder?
    -- Select One --12
30. How many cans of Air Freshener?
    -- Select One --681012
31. How many bottles of Hand Sanitizing Gel Pumps?
    -- Select One --12
33. How many cans of Disinfectant Spray?
    -- Select One --246
34. How many canisters of Sanitizing Wipes?
    -- Select One --246
36. How many cans of Furniture Polish?
    -- Select One --234
37. How many bottles of Bleach?
    -- Select One --12
39. How many cases of 33-Gallon Trash Bags?
    -- Select One --123
40. How many cases of 60-Gallon Trash Bags?
    -- Select One --123
44. Please select your items:

    1. Jumbo Toilet Tissue (8 rolls/case)
    2. Regular Toilet Tissue (96 rolls/case)
    3. Multi-Fold Paper Towels (4000/case)
    4. Pine Oil Concentrate Disinfectant Cleaner
    5. Toilet Bowl Disinfectant Cleaner (6 bottles/case)
    6. Pink Lotion Dispenser Soap
    7. "Comet"-Type Cleanser (24 per case)
    8. Air Freshener (12 per case)
    9. Disinfectant Spray - "Lysol" Aerosol Spray
    10. Furniture Polish (12 per case)
    11. Glass Cleaner (12 per case)

    1. Waxed Paper Sanitary Napkin Bag Liners
    2. Wypall Disposable Wipes (18 packs/case)
    3. Broom
    4. Mop Handle
    5. Mop Head
    6. Super Sorb Absorbent Powder (24 per case)
    7. Hand Sanitizing Gel Pumps
    8. Sanitizing Wipes
    9. Bleach
    10. 33-Gallon Trash Bags (200 bags/case)
    11. 60-Gallon Trash Bags (100 bags/case)
46. How many cases of Jumbo Toilet Tissue?
    -- Select One --12
47. How many cans of Glass Cleaner?
    -- Select One --234
49. How many cases of Regular Toilet Tissue?
    -- Select One --1
50. How many packs of Waxed Paper Sanitary Napkin Bag Liners?
    -- Select One --1
52. How many cases of Multi-Fold Paper Towels?
    -- Select One --12
53. How many cases of Wypall Disposable Wipes?
    -- Select One --1
55. How many bottles of Pine Oil Concentrate Disinfectant Cleaner?
    -- Select One --12
56. How many brooms?
    -- Select One --1
58. How many cases of Toilet Bowl Disinfectant Cleaner?
    -- Select One --1
59. How many mop handles?
    -- Select One --1
61. How many packs of Pink Lotion Dispenser Soap?
    -- Select One --24
62. How many mop heads?
    -- Select One --1
64. How many cans of Comet-"Type" Cleanser?
    -- Select One --123
65. How many cans of Super Sorb Absorbent Powder?
    -- Select One --12
67. How many cans of Air Freshener?
    -- Select One --36912
68. How many bottles of Hand Sanitizing Gel Pumps?
    -- Select One --12
70. How many cans of Disinfectant Spray?
    -- Select One --2
71. How many canisters of Sanitizing Wipes?
    -- Select One --12
73. How many cans of Furniture Polish?
    -- Select One --234
74. How many bottles of bleach?
    -- Select One --1
76. How many cases of 33-Gallon Trash Bags?
    -- Select One --12
77. How many cases of 60-Gallon Trash Bags?
    -- Select One --12
81. Do you currently have a food service program?*
    -- Select One --YesNo
83. Please select an item:

    1. Hand Sanitizing Gel Pumps
    2. Sanitizing Wipes
    3. Disinfectant Spray
85. Please select an item:

    1. Hand Sanitizing Gel Pumps
    2. Sanitizing Wipes
    3. Disinfectant Spray
    4. Bleach
87. How many bottles of Hand Sanitizing Gel Pumps?
    -- Select One --1
88. How many canisters of Sanitizing Wipes?
    -- Select One --1
90. How many cans of Disinfectant Spray?
    -- Select One --1
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92. 1. Receive an email copy of this form.
93. Email address

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94. Submit

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