Request edit access
BWIB Community Impact Initiative
Black Women in Business (BWIB) has decided to help serve seniors (60+) during the COVID-19 crisis. BWIB Headquarters will become a food distribution center that will provide FREE food and essentials to the seniors in our community! Once your form is submitted, a team member will contact you to schedule a pick-up time during office hours! Please put "N/A" in each field that does not apply to you. If you have any additional questions please contact us at and put 'COVID19' in the subject line!

Thank you for cooperation as this will ensure that everything is handled as smooth as possible!
Sign in to Google to save your progress. Learn more
Email *
Have you recently lost a job due to the COVID-19 Pandemic? *
Please check the appropriate income bracket for your household in 2019: *
Name (Last name, First) *
Phone Number *
Address *
Date of Birth *
Number of people in Household: *
Please list any allergies and/or health restrictions below: *
Person submitting the form: *
Please select any additional assistance that you may possibly need: *
Comments, Questions, Concerns
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy