Aplicación de elegibilidad

Applicant Contact Information

Name of Applicant *

Nombre

Apellidos

Applicant Address *

Address Line 1

Address Line 2

City

State

Zip Code

Applicant Mobile Phone *

Applicant Email *

Business Contact Information

Legal Name of Business *

Doing Business As (DBA) *

The name the business is using to the public.

Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone *

Business Mobile Phone

Business Email *

Business Website or Social Media URL

Must include the http://www. prefix to be considered a valid URL

Business Information

Which industry is your business primarily in? *

Select One

Explain Your Industry *

Do any of the following describe your business? *

Non-profit organization/business;
Lobbyists;
Businesses that involve the sale of medical ir recreational cannabis;
Private club or business that limits membership for reasons other than capacity;
Businesses with at least 33% of its gross annual revenues from legal gambling activities;
Businesses engaged in production or wholesale selling of tobacco products, vaping, liquor or sexually explicit materials;
Pawnshop, liquor store, adult bookstore, non-therapeutic massage parlor, strip club or nightclub;
Storage facility, trailer-storage yard or junkyard;
A business in which a majority owner or member of the immediate family is an elected official of the City of New Rochelle;
Businesses restricted to patrons above the age of 18;
Franchises;
Chains;
None of the Above

How many employees does your business currently employ at all locations? Employees are defined as all persons receiving a W-2 from the business, including the owner(s) if applicable. *

How many years has this business been operating in New Rochelle? *

Select one

Please provide an estimate of your past year's revenues. *

COVID-19 Impact

Has your business experienced a loss of income ≥ $1,000 due to COVID-19? *

What other impacts have affected your business in dealing with COVID-19? (Select all that apply) *

Temporarily closed due to state executive order
Reduced staff hours
Laid off employees
Changed product / service mix
Changed product / service delivery method
None
Other (Please specify)

Please specify *

Has this business received Federal or State funding (loans, grants or other assistance) related to the COVID-19 emergency, including but not limited to Bank loans, SBA loans, Public or private loans, grant funding, etc.? *

Financial Assistance

What size grant are you requesting? (Documentation will be required to determine eligibility for amount of grant funds based on planned usage.) *

$5,000
$10,000
Other amount (Please specify)

Please specify finance Assistance *

How do you intend to implement these grant funds to ensure the survival of your business? (Please check all that apply) *

Pay Staff
Pay Utilities
Pay rent
Purchase stock / Inventory
Prepare to meet increased safety and social distancing protocols
Build e-Commerce capability
Other (please specify)

Please specify how do you intend to implement these grant funds

Owner Information

(If you want to be considered for a microenterprise stabilization grant, the federal government requires that you complete these questions, if applicable)

Applicant / Owner Information

What was the owner’s family’s total gross income in 2019? *

How many persons are in the owner’s household? *

Is the Applicant a United States Citizen or Legal Permanent Resident? *

Are you age 18 or older? *

Are you a student? *

Business Co-owner

(if applicable) Co-owner(s) must also meet the income eligibility requirement.

My business does have any co-owners

Co-owner Name *

Nombre

Apellidos

Co-owner Email *

What was the co-owner’s family’s total gross income in 2019? *

How many persons are in the co-owner’s household? *

Is co-owner a U.S. Citizen? *

Yes
No
Lawful Permanent Resident

Is the Co-owner age 18 or older? *

Is the Co-owner a student? *

Do any of the following describe your business? (Check all that apply.) *

Minority or woman-owned businesses
Veteran owned businesses
Disabled-owned business;
None of the above

By signing this application, I certify that all information contained in this application is true and complete. I made no misrepresentation, nor did I omit any pertinent information.

I UNDERSTAND THAT ADDITIONAL FINANCIAL AND BUSINESS INFORMATION WILL BE REQUIRED TO COMPLETE THE APPROPRIATE APPLICATION BEFORE A DETERMINATION OF FUNDING WILL BE MADE.

Submitted By: *

Submitted by role in business: *

Date of Submission: *//