Name(s)
*
Business Name
*
Cell Phone
*
Business Phone
Home Phone Number
Email Address
*
Business Physical Address
*
City
*
Zip code
*
Business Mailing Address
*
City
*
Zip code
*
Number of Years in Business
*
Number of Employees (excluding owners)
*
Services or Products you provide
*
Impact of Disaster on Business Operations
*
Application Amount (up to $2000)
*
Are you willing to provide us with documentation (receipts, cost breakdowns, etc) regarding the use of these funds?
*
Select an option:
Yes
No
Are you willing to provide a progress report on status of business and the effect of the Business Grant on the sustainability of your business?
*
Select an option:
Yes
No
To what degree, if any, are you insured for any of your losses?
*
What is your current status of any insurance settlement/payments?
*
Have you received any other resources, donations, or grants as a result of the disaster? If so, please describe.
*
Title
*
Date
*
Applicant Signature
*
Date:
Thursday, 6 November 2025 (EST)
Name:
Type your name to sign this document:
Typing name is equivalent to a handwritten signature
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Approved
Denied
Committee signature
Committee signature
Committee signature
Date
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*
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