Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
  1. These N95 masks will only be distributed to growers, processors, farm labor contractors, and other agricultural industrial entities that perform pesticide applications or have employees who may be exposed to heavy dust or COVID.

  2. You are REQUIRED to be a permit holder or registered to do business as an agricultural entity with the Merced County Agricultural Commissioner to receive the masks. Masks are intended to be used for pesticide applications, COVID, and heavy dust only. Please limit your request to a two month supply.

  3. Please fill out the following contact information and number of masks requested and submit. Depending on the availability of masks, you will be contacted to arrange for pick-up. There will be a limit on the number of boxes allowed per customer, to be determined.
  4. All recipients of any of these state-supplied personal protective equipment (PPE) items are certifying to the following: The Recipient acknowledges that state-supplied PPE is to be used exclusively for the protection from wildfire smoke, heavy dust, COVID, or for the application of pesticides by employees engaged in agriculture or agricultural related businesses; The Recipient is prohibited from selling state-supplied PPE; The Recipient is prohibited from re-distributing state-supplied PPE in exchange for any other item or service of value or for use other than the intended purposes; The Recipient must not commit waste, fraud, or abuse in the course of using or distributing PPE; The Recipient shall only use state-supplied PPE in accordance with industry standards or uses authorized by the state; Upon submission of this form and receipt of these terms and conditions, the Recipient is agreeing to the terms and conditions.

  5. Leave This Blank:

  6. This field is not part of the form submission.