Business Assistance Fund - Application Questionnaire The Chamber Executive Committee will review all applications and make recommendations. Please complete/submit the following. Business Name * Contact Person * Phone Number * Email * Please explain your hardship and its financial impact and indicate whether you have received or are expecting to receive money from other sources - please be specific. * If awarded a grant from the Chamber, 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 *