Request for SOVA COVID‐19 Supply Chain Assistance

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Request for SOVA COVID‐19 Supply Chain Assistance

Complete this form to apply for COVID-19 assistance with personal protective equipment (PPE) or professional services. Businesses using a pre-qualified supplier will be required to provide a one-to-one match and may receive assistance of up to $20,000 for any one project.

Business Name

Address

City

State

Zip

Contact Name

Contact Title

Contact Phone

Contact Email

Select your locality

I need assistance with:

Personal Protective Equipment (PPE)

Plexiglass and Installation

Furniture/Fixtures

Disinfectant

Goggles/Face Shield

Barriers/Dividers

Gowns

Respiratory Masks

Signage

Gloves

Modification and Expansion Materials

Other PPE:

Professional Services

Legal

Accounting

Human Resources

Marketing and Communications

E-Commerce and Web Design

Janitorial and Deep Clean Services

Supplier Identification

Business Continuity and Emergency Plans

Architecture, Design, Engineering or Construction

Miscellaneous Mandated Professional Services

Telecommunication Services

Other Professional Services:

Description of Assistance Need

If more applications are received than funding can accommodate, applications will be ranked by need and ability to impact regional outcomes.

Describe your assistance need:

Have you received other COVID-19 funding? Yes No

Other Sources of funding for COVID-19 Expenses

List other sources of funding for COVID‐19 expenses that you have applied for or received:

1) From

For

Amount

2) From

For

Amount

Does your funding request overlap funds received from the sources listed above? (This fund cannot duplicate other funding received.)

Please describe any funding overlap:

Request for SOVA COVID‐19 Supply Chain Assistance

Potential Suppliers

Have you already considered or heard referrals for potential COVID‐19 suppliers? Yes No

If yes, have you used them previously? Yes No

Provide any potential supplier’s contact information:

Company Name

Contact Name

Address

Phone

Include contact information for another potential supplier?

Provide any potential supplier’s contact information:

Company Name

Contact Name

Address

Phone

Include contact information for another potential supplier?

Provide any potential supplier’s contact information:

Company Name

Contact Name

Address

Phone

Federal Tax Classification

Select your Federal Tax Classification Individual/Sole Proprietor C Corporation S Corporation Partnership Other

Other Federal Tax Classification

Organization Type

Please indicate your organization type For Profit Nonprofit

Check all that apply to your business

Micro

Small Business Certified

Minority Owned

Woman Owned

Veteran Owned

8(a) Qualified Small Business

Other Applicable Classifications:

Is your business listed on any of the following?

eVA Procurement Portal

Federal Procurement Data System (FDPS)

AbilityOne

US General Services Administration (GSA)

Defense Logistics Agency (DLA)

Veterans Affairs (VA)

Other Listings:

Employees

Number of Employees Pre‐COVID:

Current Number of Employees:

Signature

To complete this application, please enter your name in the field below.

By entering my name below, I certify that all of the information listed above is accurate.

Applicant Name

Request for SOVA COVID‐19 Supply Chain Assistance

Thank You!