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2. Name
3. Email Address
5. Business Address
7. City
8. State
9. Zip Code
11. Phone Number
13. Industry Sector ?
    -- Select One --RetailRestaurant/HospitalityArtsProfessional ServicesManufacturing/Food & Beverage ProductionHealthcareTrade/LogisticsHigh Technology/Life Sciences
15. Do you have business interruption insurance?
16. Did you see a year-over-year decline in gross receipts in February? If yes, by what percentage?
18. Are you experiencing a year-over-year decline in gross receipts in March? If yes, by what percentage?
19. As of March 1, 2020, how many full-time (at least 40 hrs. per week) employees did you have? How many part-time?
21. Have you had to reduce the hours worked by your full-time staff in the last few weeks?
22. Have you eliminated any positions since March 1?
24. How concerned are you that you may have to close your business due to COVID-19 impacts?
26. What would be most helpful for your business in the near-term?

    1. Grants
    2. Loans
    3. Technical Assistance
    4. Unemployment Benefits
    5. Other (fill in below under Comments)
28. Comments
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30. 1. Receive an email copy of this form.
31. Email address

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32. Submit

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