COVID-19 Grant Application Form

Name of Business

Business Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Business Email

example@example.com

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Person

First NameLast Name

Phone Number of Primary Contact Person

Please enter a valid phone number.Format: (000) 000-0000.

Business License Number

Is this a lease property?

Is this residential or commercial?

Year of Establishment

Number of Employees

Payroll Type

Total Business Revenue (2020) ($)

Total Business Revenue (2019) ($)

W-9 IRS Form

Invoices and receipts for reimbursement

Certificate of Good Standing

Copy of State Business Licenses

Does the business have outstanding liens or pending legal issues that cause by the pandemic?

How's the funding of the business?

Does the owner have any pending legal issues?

Was your business affected by the pandemic?

Did the pandemic cause issues like daily business operations?

Please describe below the business issues you encounter during the pandemic?

Was the number of your employees affected because of the pandemic?

Were you able to hire new employees during this pandemic?

Were there any lay-offs?

Did you already apply for financial support from another institution or from the government?

If yes, please indicate the institution

Application status

Please describe the revenue and loss of your business during this pandemic.

How much funding does your business need? Please indicate the total amount requested. ($)

In addition to that, upload a summary of costs document and attach it to the form. (reopening costs, rent costs, etc.)

Where will you use the funding if granted?

When does your business need the fund?

I confirm that all information I entered in this form is accurate and true.

I understand that the information in this form is not for public use and remains confidential depending on the agreement.

I certify that all purchases, invoices, certifications, financial statement, and other legal documents are thoroughly checked and make sure it is accurate.

I understand that the grant funds are given on a first-come basis.

I understand that the application will be reviewed and thoroughly evaluated based on the criteria of the grantor.

I release this company (grantor) and its employees from any liabilities, claims, and demands that may arise during this application.

By signing this form, you agree to the terms and conditions indicated on this form.

Signature

Date Signed

Date

COVID-19 Grant Application Form

Acknowledgment