Hands Up 4 Hospo Funding Form

Contact Name

Company Name/ Outlet Name

Contact Phone Number

Business Phone Number

NZBN

GST Number

Number of Full-Time Employees

Number of Part-Time Employees

Physical Address

Zip/Postal

City

Country

Postal Address (If different from above)

Zip/Postal

City

Country

Please help me pay...

Power billPower bill

Phone/internetPhone/internet

SupplierSupplier

OtherOther

Wage Subsidy Taken?

Yes

No

Resurgence Fund Taken?

Yes

No

Able to Operate Click and Collect

Yes

No

Rent Relief Available to You

YesYes

No

Average % Turnover Drop

Tell us what some support would mean to you?

100 words or less

Yes, I agree to the terms and conditions

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