Relief Recipient Form - ChamberRVA

Relief Fund Graphic

We are pleased to notify you that your application for the RVA Small Business Relief Fund grant has been approved. Please complete the form below so we can deposit the grant funds into your business banking account.

You must submit the form below by Noon (12:00 p.m.) Monday, June 1, 2020 in order to complete your acceptance of the grant.

Company Name*
Please enter exact name used in original application
Employer Identification Number EIN*
Please enter exact EIN used in original application
Business Address*
Please enter address as indicated on previously submitted Form W9

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Contact
Name*
Phone*
Email*
Banking Information
Bank Name*
Bank Routing Number*
Bank Account Number*
Please upload scan/photo of voided check*
Max. file size: 25 MB.

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