BLNC -2019 Disaster Recovery for NC Businesses
Bu
siness Owner______________________________________________________
Last First Middle
Legal Business Name/DBA__________________________________________________________
(LEGAL BUSINESS NAME, indicate if you have DBA (Doing Business As) filed BEFORE 12/1/2017) □ YES □ NO
Type of Business: (check type)
□ Retail/Wholesale □ Service □ Agri-Business □ OTHER_________
□ Manufacturing: □ Construction □ Commercial Fisher
DID YOU HAVE PHYSICAL DAMAGE to the BUILDING? □ YES □ NO
Did you lose product? □ YES □ NO, Did you lose sales? □ YES □ NO
Do you have employees? □ YES □ NO, If yes, How Many? ______________
Displaced employees?
□ YES □ NO
Physical Business Address: ____________________________________________
______________________________________________________________________________
County: _____________________ Zip Code: _______________________________________
Phone: ______________________ Best Time to Call? ________________________________
Cell Phone: ___________________ Email: _________________________________________
Has Owner done any of the following: (CHECK NEXT TO RESPONSE)
Applied to FEMA? □ YES □ NO
Applied to SBA? □ YES □ NO
Filed with Insurance? □ YES □ NO
Assistance Needed/Other Issues or Comments:
□ Lose of Sales/customers □ Help with vendors/suppliers; creditors
□ Help with tax issues □ Help with disaster loan application/appeals
□ Help creating an overall recovery plan □ OTHER_______________________
RECORDED
BY:_________________________________DATE:___________________________________
Please SAVE with your initials to your HARD DRIVE – ATTACH to Email
Email: BLNC@EDPNC.com
