Application for Lewis County Restaurant/Bar Employee Relief Fund

Contact Information

First/Last Name

Phone

Mailing Address

Address Line 2

City/Town

State/Province

ZIP/Postal Code

CURRENT/FORMER PLACE OF EMPLOYMENT (must be located in Lewis County)

Please upload PROOF OF EMPLOYMENT (i.e. 2020 paystub, letter from establishment notifying layoff/reduction of hours)

Please explain how your employment was negatively effected by the COVID-19 pandemic.

By checking this box, I understand and acknowledge that I am legally agreeing to all of the statements in this document.

Today's Date

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