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* 1. Contact Name

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* 2. Company Name

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* 3. What industry does your business operate in? (please provide NAICS code if available)

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* 4. Please describe the impact of Coronavirus on your business.

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i We adjusted the number you entered based on the slider’s scale.

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* 5. What is the current status of your business?

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* 6. How many employees did you have prior to March 1, 2020?

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* 7. How many employees do you currently have or expect to have in the next 30 days?

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* 8. Have you been in contact with a lender to get access to capital made available through the CARES Act?

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* 9. If you have contacted a lender or may do so, do you have a pre-existing relationship with that lender?

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* 10. Do you believe you will qualify for the Paycheck Protection Program?

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* 11. Please explain why you believe or do not believe you will qualify for the Paycheck Protection Program.

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* 12. Do you believe you will qualify for capital made available through any other portion of the CARES Act?

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* 13. Would you like someone from STORE Capital to contact you and see if we can help?

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* 14. Please provide a preferred phone number and time to contact you.

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