2012 June Floods

SURVEY OF BUSINESSES AFFECTED: 2012 JUNE FLOODS

THIS IS NOT AN APPLICATION, it is a survey of affected businesses to establish a means of communication and begin preliminary damage assessment. Data collected on this form will be used by the Minnesota Department of Employment and Economic Development (DEED) and the State of Minnesota in efforts to assist communities and businesses in the recovery process.

NOTE: items marked with an asterisk are required

1.

Job Title

First Name *This question is required.

Last Name *This question is required.

Your primary phone: *This question is required.

Secondary phone:

E-mail Address *This question is required.

Fax Number

Company Name *This question is required.

Street Address *This question is required.

County *This question is required.

City *This question is required.

Zip Code *This question is required.

Today's Date *This question is required.

State

Apt/Suite/Office

2. Total number of employees in business:

3. Number of employees not working as a result of flooding:

4. Type of business

5. Is business's plumbing/sanitation functional?

Yes
No

6. Did business location close due to flooding? (Choose ONE) *This question is required.

Yes
No
No, but moved to a temporary location

Street Address of temporary location

First Name

Last Name

Title

Company Name

Street Address

Apt/Suite/Office

City

State

Postal Code

Country

Email Address

Phone Number

Fax Number

Mobile Phone

URL

7. Is your residence uninhabitable?

Yes
No

8. Is your residence's plumbing/sanitation functional?

Yes
No

9. Residence address:

First Name

Last Name

Title

Company Name

Street Address

Apt/Suite/Office

City

State

Postal Code

Country

Email Address

Phone Number

Fax Number

Mobile Phone

URL

10. Describe the damage to your business location:

11. How can DEED/State be of assistance to your business? Questions?