Business Name*

Employer Identification Number (EIN) or Social Security Number*

Select your Precinct*

Main Contact Name*

Email Address*

Please confirm Email Address*

Primary Phone (111-111-1111)*

Street Address*

City*

State*

Zip Code*

Number Of Employees

Number of Business Locations in Harris County

Business Type

Please choose one option for the loss in revenue post COVID-19 (Since March 1, 2020)

Did you apply and receive funding from any of the recently approved Harris County Programs to assist Small Business Assistance?

Was your business impacted significantly by state or local COVID-19 executive order closure requirements? (i.e. Have you changed the primary focus of your business?) Please describe.

Veteran Owned Business

Women and/or Minority Owned Business

Please indciate the number of items you are requesting below.

Gloves (Maximum of 200)

Masks (Maximum of 200)

Thermometer (Maximum of 2)

Please enter your email address above to receive a copy of your submission. You must bring it with you (printed or digital) to pick up the PPE’s from your selected County Precinct on the date, time and location to be determined.

For a digital copy and/or to print: please click HERE before you hit the submit button. Then print or save as pdf.

For more information or assistance, please send an email to BusPPEReq@pur.hctx.net or call 713-274-4400.

 
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Title *

BusinessName

EINorSSNum

OwnerFirstName

OwnerLastName

PrimaryPhone

EmailAddress

ConfirmEmailAddress

StreetAddress

City

State

ZipCode

NumOfEmployees

NumBusinessLocationsHC

BusinessesType

VetOwned

MinorityWomenOwned

GlovesNum

ThermometersNum

MasksNum

Precinct

COVID19RevenueLoss

FundingReceived

SignificantlyImpacted

Attachments

 
PPEBusinessRequest