Application

Organization Name

Street Address

City

State/Province

ZIP / Postal Code

Contact Name

Phone

Contact Title

Email Address

Which category best describes your business?RetailNon ProfitRestaurantWellness

Do you rent or own your building?RentOwn

DateDate your physical location closed to the public.

NumberNumber of paid employees prior to closing.

NumberHow many employees consider your organization their sole household employer.

NumberApproximate number of people who patronized your business in 2019.

TextHow has the "Safer at Home" order impacted your business financially? (100 words or less) Specific examples and financial assessments are appreciated.0 / 800

TextHow will impact relief funds help your business and our community? (100 words or less) Specific examples and financial assessments are appreciated.0 / 800