GO Virginia Retooling Initiative Application

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Primary Point of Contact

Name

Title

Email Address

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Phone Number

Company Situation

Are you in the process of using your capabilities or company resources to produce medical supplies or PPE in response to the COVID 19 shortage?

What is your level of interest in committing (or continuing) some of your company’s time and resources to becoming a supplier for PPE and/or medical supplies?

What % of sales are currently in medical supplies or PPE?

What is your expected timeline? Are you interetestd in producing medical supplies or PPE as a long term market or to temporarily pivot to help fill short term demand?

Please briefly describe your company's products and/or services.

What products would you target as a Supplier (click all that apply)

Finished PPE, commodity (clothing, gowns, gloves)

Finished PPE, specialized (surgical masks, N95 masks,face shields, PAPR)

Finished Sanitizing (hand sanitizer, cleaning products, sterilization methods)

Finished Drug or therapy treatments

Finished Ventilator or breathing device

Component inputs (assemblies, parts or production components for anything above)

Raw materials (chemicals, textiles or other raw goods)

Other

If you selected other above, please specify.

Please provide a detailed description of Target Product as a Supplier

Please describe your current and targeted production capacities by product line:

Please describe your current capability to produce the target products in the long term:

Do you currently have regulatory approvals required for the target products or are you operating under an Emergency Use Authorization?

What gaps in capability would you most need help with to produce medical supplies or PPE in the long term?

What would be the quantifiable impacts to your business if you are able to develop sustainable production capability for the target products:

Terms and Conditions

All program benefits are delivered as services.

At company's request, a proposal for service will be prepared for consideration.

Company cost share for services will equal 10% cash (non-refundable) upon acceptance. Program will bear remainder.

I am authorized to execute this application on behalf of my company.

Signature Name

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Today's Date

Signature

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Company Information

Primary Point of Contact

Company Situation

Terms and Conditions