COMPANY INFORMATION
Business Name:
Address:
City, State and Zip:
Contact Name:
Contact E-mail:
Contact Phone:

FACILITY INFORMATION
Has there been damage to the businesses’ facility? YesNo
If yes, what type of damage occurred?

Is temporary office space needed? YesNo
If yes, explain office space need?

Square footage needed:
Length of time:

WORKFORCE
Are workers able to get to your facility? YesNo
If not, why?

What is the estimated number of jobs impacted due to non-operation?

UTILITIES
Are there any utilities currently interrupting the operation of your business?

TRANSPORTATION/MARKETS
Are you able to get supplies to the facility? YesNo
Are there any needed supplies?

OTHER KEY FACTORS OR ISSUES IMPACTING YOUR BUSINESS

Would you like to have a call with a JEDCO representative for any follow up resources or information? YesNo

Enter the characters from above:

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