Dillon's Small Batch Distillers Request Form for First Responders (hospitals, doctors, nurses, fire, police, EMS, LTC facilities, clinics)

It is understood that by completing this form, it does not guarantee that we have been able to allocate sanitizer. We are serving as many as we can based on need and what we are able to produce. Due to the volume of requests, it may be at least 48 hours before you hear back from us. *

Yes

How would you prefer to receive the sanitizer? *

Pick-up (Beamsville)

Shipping ($15 per case - Ontario only)

Pick-up (Toronto)

Pick-up (Guelph)

First Name *

Last Name *

Email Address *

Company/Organization *

Contact Phone Number *

Business Phone Number *

Street Address *

Is this a home or business address? *

Home

Business

City *

Postal Code *

I would like to be placed on a list to purchase supplies if allocated free quantities run out. *

Yes

Requested quantity

Comments/Feedback- Please also indicate how many people/department(s) this will service. *

Please provide work ID or identifying information to confirm credentials *

Preferred pick up options *

Pick-up (Guelph)

Pick-up (Beamsville)

Pick-up (Toronto, Parkdale area)

Ship ($15 per case - Ontario only)

Do you require shipping? This can be available based on location (Pre-paid shipping required - $15 per case) - Please provide shipping details in comments below.

Yes

Please provide shipping details & special instructions *

Thank you for completing this request form. These forms are downloaded every two days and an email will be sent to inform you when and where you are able to pick-up sanitizer or to gather more details if you have requested sanitizer be shipped. Please note that we are a small team and working around the clock. We appreciate your patience. *

yes

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