Main Street Economic Revitalization Program

Contact 1

Business Phone Number

Business Owner Email

Business Website

First Name

Last Name

Company Legal Name

Number of years in operation

0 - 5

5 -10

10 -15

15 +

When was your Business registered with the state?

Employer Identification Number

What is the legal structure of your company?

Sole proprietorship

Limited Liability Company

S Corporation

C Corporation

Nonprofit 501c3

Constituent Info - Individuals

Business Name

Number of employees

Business Address

State/Province

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

City

Postal Code

Was your Business Impacted by COVID-19?

Yes

No

Was your business impacted by the civil uprising/unrest (George Floyd events)?

Yes

No

How has your organization been impacted by COVID-19

Please describe the purpose of your business or mission statement

How has your business been impacted by civil unrest

Please include the target population and any plans for community and stakeholder engagement efforts

Summary of Project Location

Summary of Proposed Project/Work

Summary of Project Completion Plan

Project Budget

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