ERC Intake
Eligibility Questionnaire
Name
*
First Name
Last Name
Are you the business owner or an authorized representative of the business owner?
*
Please Select
I am the business owner
I am an authorized representative of the business owner
I am an individual employee
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Legal Business Name
*
Business EIN
*
Business Formation Year
*
Please Select
2019 or before
2020
2021
Business Industry
*
Full-time W2 employees in 2021
*
Check any of the following that caused a disruption to your business operations and was the result of one or more COVID-19-related governmental orders.
*
Full shutdown
Partial shutdown
Interrupted operations
Supply chain interruptions
Inability to access equipment
Limited capacity to operate
Shifting hours to increase sanitation of your facility
Employee absences due to quarantining requirements, exposures, or positive COVID cases
Other
Appointment
Email
*
example@example.com
Signature
*
Please verify that you are human
*
Continue
Should be Empty: