Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Employer Contact *

First Name

Last Name

Employer Phone *

(###)

###

####

Is your employer currently closed due to COVID-19? *

Yes

No

If your employer is closed on what date did your employer close?

MM

DD

YYYY

If your employer is closed on what date is your employer expected to reopen?

MM

DD

YYYY

Are you under mandatory quarantine? *

Yes

No

If you are under quarantine when did your quarantine start?

MM

DD

YYYY

Are you COVID positive? *

Yes

No

If you are COVID positive on what date were you tested?

MM

DD

YYYY

Do you have more then one job? *

Yes

No

Are you receiving unemployment? *

Yes

No

Are you receiving paid sick leave? *

Yes

No

Is a percentage of your income derived from tips? *

Yes

No

By submitting this application you agree to the following terms and conditions: *

Applications are processed on a first come, first serve basis. Submitting an application is not a guarantee that you will qualify for assistance or a guarantee that if you apply you will receive assistance. Assistance amounts are determined at the sole discretion of the CRRF Review Board and all decisions are final. By applying you hereby give permission for CRRF staff & volunteers to validate your data as required to evaluate your application. This validation may included contacting your employer to verify employment. Additional records or documentation may be required to process your application. You agree to hold harmless the Capital Regional Restaurant Fund, it's founders, employees, volunteers and review board from any damages that may arise directly, or indirectly, as a result of your application or any awarded gift. All financial assistance awards granted by the CRRF Review Board are considered gifts.

Agree

Disagree