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Business Recovery Grants App Form
ABC business
Email address
Organization Legal Name:
Your answer
Doing Business As Name:
Your answer
Business Physical Address (Street-City-Zip):
Your answer
Business Phone:
Your answer
Business Website:
Your answer
CEO / Owner Full Name:
Your answer
Primary Contact Full Name & Title:
Your answer
Primary Contact Phone (if different from Business phone):
Your answer
Primary Contact Email:
Your answer
Is Your Business A Current Chamber Member?
Statement of Business Purpose, Product(s), Service(s):
Your answer
My Business Insurance Coverages Include (Having or not having insurance will not impact a request for funding)
Other Sources of Funding Being Received for Business Recovery:
Your answer
If Granted, Money Will Help to Cover:
Your answer
Signature of Owner:
Your answer
Date Completed
MM
/
DD
/
YYYY
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