Application Form
Please complete this questionnaire to determine your eligibility for a free PPE Kit and return via email to
your economic development department promptly. Kits are in limited supply and will be distributed first-
come, first-served to qualified businesses in Staunton, Augusta County or Waynesboro with 15 or less
employees. If you qualify, you will be notified when and where to pick up your kit by your economic
development department.
Contact information
Business Name:
Business Address:
Phone Number:
Is your business located in Staunton, Augusta, or Waynesboro?
Yes No
Which jurisdiction are you located in? Staunton Augusta Waynesboro
Do you have a current business license in that jurisdiction? Yes No
Are your taxes and fees to your jurisdiction current? Yes No
Is the provided business address a physical location that receives customers? Yes No
Do you have 15 (full-time equivalent) employees or less? Yes No
How was your business impacted by COVID-19?
Will your business be open for customers by June 10, 2020? Yes No
The SAW MSA Recovery Task Force free PPE kit grant initiative has been funded by the Cities of Staunton and Waynesboro
and Augusta County through US Treasury CARES Act funding; City of Waynesboro Economic Development Authority; United
Way of Greater Augusta; and the Community Action Partnership of Staunton, Augusta and Waynesboro (CAPSAW).
Business Owner Signature: __________________ Date: ______________
For office use only
Date received: _____________ Time received: ____________ Qualified: Yes No
Kit #: _________ E-mail Notification Sent: ________________
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