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 * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming DC 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 *