COVID-19 Response Form

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Please complete the form below. A member of the Business Action Team will follow up within 24-48 hours. If you require immediate assistance, please email: lridgeallen@eriepa.com. All information is confidential and will only be used internally to connect your business with proper resources and information as it becomes available.

Business/Organization: *

Contact Info | Please type your full name, email address, and phone number in the box below:

Briefly describe the nature of your business.

How much working capital would you need to cover bare essentials through the next four to six weeks? *

$1 - $5,000

$5,001 - $10,000

$10,001 - $20,000

$20,001 - $50,000

$50,0001 - $200,000

Over $200,000

Unsure/I don't know

None at this time

How many employees do you have? *

1-10

11-20

21-30

31-40

41-50

51-60

61-70

71-80

81-90

91-100

100+

How is COVID-19 disrupting your business specifically (Check all that apply)? *

Decrease Sales / Canceled Orders

Delayed Shipments

Supply Chain Disruptions

Decreased Access to Raw Materials

Employee Absence

Working Capital Concerns

General Public Perception Issues

Lack of Formal Policy/Procedure in Place for Our Business

Event Cancellation

Employee Travel Concerns

Client Travel

School Cancellations / Child Care for Employee Attendance

Work Remote Policy/Implementation

IT/Infrastructure Concerns/Capacity

Basic Work Supplies

General working capital

Lost Revenue

Payroll Challenges

Rent/Lease Payments

Utility Payments

Loan Repayment

Other:

Required

Does your company have capacity and/or services to assist local businesses affected by COVID-19?

Yes

Maybe

Clear selection

If so, please briefly describe below.

Any other concerns or questions?

Submit

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