Business Assistance Fund - Application Questionnaire

The Chamber Executive Committee will review all applications and make recommendations. Please complete/submit the following.

Business Name *

Address

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Email *

Contact Person *

Corporate Title *

Phone Number *

Please explain your hardship *

How long has your business been in existence? *

How many employees, including yourself, do you have? *

Have you kept your employees in place throughout the Covid-19 pandemic? If not, please describe details (how many let go, furloughed vs. laid off, hired back, etc.) *

Did you receive PPP assistance or any other federal/state assistance already? If so, please provide details. *

Are you a member of the Rome Chamber or were you forced to discontinue your membership due to Covid-19 difficulties? *

How has the pandemic directly affected your company’s financials? (e.g. gross sales comparison with 2019, net profit, etc.). Please provide specifics. *

Are you currently in arrears on any accounts payable? Please describe. *

If awarded the Business Assistance Fund, what would it be used for? *

Please provide any further information that you would like this committee to be aware of.

Affirmation and Signature

All information submitted on this application shall be kept confidential. I affirm that all information on this application is complete and true and that I have authority to submit on behalf of the applicant’s company. No information has been withheld which would affect my application unfavorably. I understand that misrepresentation can result in disqualification of my application.

Typed Signature *

Business Assistance Fund - Application Questionnaire

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