GA Request for Assistance
Basic Information
Name
*
First Name
Last Name
NRDS ID
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Name:
*
Date
*
-
Month
-
Day
Year
Date
Details
Type of Assistance Needed:
*
Jurisdiction:
*
Please Select
Orange County Unincorporated
Seminole County Unincorporated
Municipality:
*
City within county you are seeking assistance for.
Are you seeking assistance on legislation or on government services?
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Legislation
Government services
If seeking assistance on legislation, what are you hoping to achieve with the assistance from GA?
Provide background details on the issue/legislation including key facts, history and current status.
If seeking assistance on government services, what are you hoping to achieve with the assistance from GA?
Provide background details on the issue/legislation including key facts, history and current status.
Describe how the issue/legislation affects the industry, business, or community:
*
Are there any critical deadlines?
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Yes
No
Deadline:
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Month
-
Day
Year
Date
Are there any potential challenges or obstacles that GA should be aware of?
Location of Assistance Needed:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Impact/Urgency
Reason for Request:
Number of people affected:
Estimated number of individuals impacted by the issue.
Resources and Support
What resources do you currently have to address this issue?
Have you received any assistance before for this issue? If so, from whom and what was provided?
Additional Information:
Attach any photos, documents, reports or data that can help in understanding the situation.
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Permission to Share information:
Do you give permission to share this information with relevant agencies for better assistance coordination?
*
Yes
No
Preferred Method of Communication:
*
Phone
Email
Mail
Other
Specific collateral assets needed:
Please verify that you are human
*
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