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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 INFO@blackwomeninbusiness.org and put 'COVID19' in the subject line!

Thank you for cooperation as this will ensure that everything is handled as smooth as possible!
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 *
MM
/
DD
/
YYYY
Number of people in Household: *
Please list any allergies and/or health restrictions below: *
Person submitting the form: *
Required
Please select any additional assistance that you may possibly need: *
Required
Comments, Questions, Concerns
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