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Request for Disaster Assistance
Registration Form
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* Indicates required question
Business Name
*
Your answer
Have you previously applied for Disaster Assistance?
Yes
No
Clear selection
Was your business awarded Disaster Assistance funding?
Yes
No
Clear selection
What type funding have you received?
EIDL Grant
PPP First Draw Loan
MS Back to Business Grant
CARES Act
Other:
Would you like assistance with PPP 2nd Draw Funding?
Yes
No
Clear selection
Location Address
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Contact Person
*
Your answer
Title/Position
CEO
CFO
Manager
Operations
Owner
Other:
Clear selection
Web address
Your answer
Year business established
Your answer
Type of Business
*
Construction
Distribution
Education
Entertainment
Financial Services
Healthcare
Hotels
Manufacturing
Real Estate
Restaurants/Eateries
Retail
School or Childcare Services
Other:
If retail, what is the primary product
Automotive Supplies
Books
Cellular Devices or Accessories
Clothing
Cosmetics
Gas
Shoes
Tires
Vitamins/Herbs
Other:
Clear selection
How many employees do you have
*
Your answer
Is this business a Certified Minority Enterprise w/COJ
Yes
No
Clear selection
What is the minority designation
African-American
Hispanic-American
Asian-American
Native-American
Female-American
Not A Minority
*Optional - Annual Revenue
Under $25,000
$25,000 - $50,000
$50,000 - $100,000
$100,000 - $200,000
$200,000 - $300,000
$300,000 - $400,000
$500,000 & Above
Clear selection
*Optional - Are you interested in Small Business Development Center (SBDC) services
Choose
Yes
No
*Optional - Would you like to certify as a minority vendor w/City of Jackson
Choose
Yes
No
*Optional - Are you interested in mentoring business start-ups
Choose
Yes
No
Comments
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