Must be completed by May 29, 2020

All Required Fields * must be completed

City / State / Zip
Please check all boxes that apply to your business or entity.
Please record your businesses’ gross receipts for the following periods:
Please check all boxes that apply to your business or entity.
Please list the amount of any federal CARES Act or COVID related loans or grants received, or projected to be received since March 1, 2020
The below certification must be made by a director, officer, or other authorized agent of the business, organization or entity.
I certify that the information entered here is accurate and complete, and up-to-date as of the date specified below. I further certify that there are no willful misrepresentations of information provided. I understand that it is my responsibility to immediately notify GOFERR in regards to any changes, corrections, or updates to the information provided. I acknowledge that completion of this form is required as part of the application process for Main Street Relief Fund Grants but in no way guarantees the applicant will receive a grant.
By submitting this prequalification and placing the symbol /s/ after their name in the signature block below, Applicant agrees and accepts use of its electronic signature as binding and final in accordance with all terms of RSA 294-E, the Uniform Electronic Transactions Act.
Authorized Signature (Place Authorized signor name in the first box below followed by /s/ in the second box below)