Community Underwriting Intake Form

CONTACT INFORMATION FOR INTERNAL USE: Business/Organization Name *

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Name of business or organization

Name *

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Name of authorized representative

Title *

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Title of authorized representative

Address line 1 *

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Address line 1

Address line 2

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Address line 2

City / Town *

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City

Postal Code *

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Zipcode

Email Address *

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Contact Email for authorized representative

Phone number *

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Telephone contact information for authorized representative

website URL *

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on-line contact point

Products and/or services offered *

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Products and/or services offered

OPTIONAL INFORMATION: Location or area served

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Location or service area

Other social media accounts

contact points on FB, IG, X, LinkedIn, TikTok, Discord, etc.

Year founded

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Year founded or duration in business

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