AVON C-50 Respirator Request Form

If your agency is requesting gas masks from ILEAS, please fill out this form and submit it for review. Even if there is no immediate plans for the purchase and distribution of gas masks, your requests are kept on file for when funding come available.

AGENCY INFORMATION

Agency Name: *

Enter the name of the agency that will receive the gas masks.

Agency Address: *

Enter the address of the agency that will be receiving the gas masks.

PERSON MAKING REQUEST

Last Name: *

First Name: *

Title: *

Enter your title for the agency you are employed.

REASON FOR REQUEST

Select all relevant boxes: *

Added a new officer.

Replacing destroyed / damaged masks.

Did not get masks in a prior distribution.

Other (describe below).

Other:

SIZING

For each of the three sizes listed below, select the number of AVON masks you are requesting. Also select the number of gas masks that need vision correction. (ILEAS will not pay for lens inserts for the vision correction)

Small:

Medium:

Large:

Vision Correction: # of masks needing corrective lens (*ILEAS does not pay for the lens inserts.)

Packages for the AVON masks include: the AVON respirator, carrier, and a canister. ILEAS is not, at this time,providing canisters apart from the one that will come with a complete mask package. Replacement canisters are the responsibility of the agency.

You will be notified when the respirators are available. They must be picked up at the ILEAS Office in Urbana.

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AVON C-50 Respirator Request Form

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