Community Impact Grant Application

Name*

First Name

Last Name

Title*

Pronouns (i.e. she/her/hers, he/him/his, they/them/theirs, etc.)*

Establishment Owner Identifies as:*

Member of the LGBTQ Community Ally to the LGBTQ Community

Establishment Owner's Ethnic/Racial Background:*

African American/Black Asian/Pacific Islander Caucasian Hispanic Indigenous/Native American Middle Eastern/North African Multi-Ethnic Prefer not to say

Other:

Establishment Owner is a:*

Veteran Person with disabilities Prefer not to say None of the above

Establishment Owner Identifies as (check all that apply):*

Cisgender Transgender Gender Non-Conforming/Non-Binary Man Woman Prefer not to say

Other:

Please upload documents affirming your status as LGBTQ*

No File Chosen

File uploads may not work on some mobile devices.

Acceptable status qualifiers include: Signed letter with contact information from two personal references attesting to LGBT status of business owner(s), National or local media articles denoting the LGBT status of business owners, Advertising/promotional materials that note the business is LGBT owned and operated, Certificates/Awards/Recognitions of the business and/or owner(s) as a member of the LGBT community, or a Letter from NGLCC affiliate chamber executive director or board member. Please contact us at GHgrant@nglcc.org for a full list of qualifiers.

Additional/Co-Owner of Establishment Identifies as:

Member of the LGBTQ Community Ally to the LGBTQ Community

Additional/Co-Owner of Establishment's Ethnic/Racial Background:*

African American/Black Asian/Pacific Islander Caucasian Hispanic Indigenous/Native American Middle Eastern/North African Multi-Ethnic Prefer not to say

Other:

Additional/Co-Owner of Establishment is a:

Veteran Person with disabilities Prefer not to say None of the above

Please upload documents affirming Additional/Co-Owner status as LGBTQ

No File Chosen

File uploads may not work on some mobile devices.

Acceptable status qualifiers include: Signed letter with contact information from two personal references attesting to LGBT status of business owner(s), National or local media articles denoting the LGBT status of business owners, Advertising/promotional materials that note the business is LGBT owned and operated, Certificates/Awards/Recognitions of the business and/or owner(s) as a member of the LGBT community, or a Letter from NGLCC affiliate chamber executive director or board member. Please contact us at GHgrant@nglcc.org for a full list of qualifiers.

Additional/Co-Establishment Owner Identifies as (check all that apply):

Cisgender Transgender Gender Non-Conforming/Non-Binary Man Woman Prefer not to say

Other:

Company Name*

Establishment Name (if different from company name)

Establishment Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Does your establishment serve food?*

Yes No

Please upload your menu*

No File Chosen

File uploads may not work on some mobile devices.

What has your restaurant done/is doing to support the LGBTQ community?*

Do you have any visible markers of LGBTQ-inclusion? (Ex. pride flag in window)*

If yes, please upload in the supporting document section below.

Do you currently or have you in the past provided financial or other support for LGBTQ causes?*

Do you currently or have you advertised in LGBTQ publications or conducted LGBTQ targeted social media marketing?*

Yes No

If yes, please upload in the supporting document section below.

Have you won any awards or recognitions as an LGBTQ Community ally?*

Yes No

If yes, please upload in the supporting document section below.

Does your restaurant have a non-discrimination policy inclusive of sexual orientation and gender identity/expression?*

Yes No

Other:

Check all that apply:*

Actively certified with NGLCC Local NGLCC affiliate chamber member None of the above

Please note: certification with NGLCC and/or membership with an NGLCC Affiliate Chamber does not affect grant eligibility

Certificate Number & Date of Expiration*

Do you have more than one establishment for which you are applying for this grant?*

Yes No

If yes, please list the name of the other establishment you are applying on behalf of:*

Are you willing be interviewed for media opportunities in relation to the grant?*

Yes No

Brief description of company*

Company Website*

Company Logo*

No File Chosen

File uploads may not work on some mobile devices.

Please provide specific examples of how your business was adversely impacted because of the pandemic:*

Evidence of need: Please attach your 2019-2020 Profit & Loss Statement*

No File Chosen

File uploads may not work on some mobile devices.

Please note: this information will not be shared beyond the judging panel and will only be used for eligibility purposes. If you are chosen as a finalist, NGLCC reserves the right to request additional financial records.

How would you use the grant funds to aid in the recovery from the above listed adverse impacts?*

Has your business received any funds from the Paycheck Protection Program or Restaurant Revitalization Fund?*

Yes No

Please note, this will not determine eligibility for this grant.

How long could your business survive current market conditions? *

Less than a year 1-3 years 4-6 years 7-10 years More than 10 years

How many years has your establishment been in business?*

Less than a year 1-3 years 4-6 years 7-10 years

Other:

How many employees do you have?*

What percentage of your employees identify as LGBTQ?*

What percentage of your employees belong to a racial/ethnic minority?*

What percentage of your employees are veterans?*

What percentage of your employees are persons with disabilities?*

Optional: Upload additional supporting documents (Ex. Marketing collateral, Award/recognitions, Photos of visible markers of LGBTQ inclusion, letter of support from NGLCC Local Affiliate Chamber, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Optional: Upload additional supporting documents (Ex. Marketing collateral, Award/recognitions, Photos of visible markers of LGBTQ inclusion, letter of support from NGLCC Local Affiliate Chamber, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Optional: Upload additional supporting documents (Ex. Marketing collateral, Award/recognitions, Photos of visible markers of LGBTQ inclusion, letter of support from NGLCC Local Affiliate Chamber, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Optional: Upload additional supporting documents (Ex. Marketing collateral, Award/recognitions, Photos of visible markers of LGBTQ inclusion, letter of support from NGLCC Local Affiliate Chamber, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Optional: Upload additional supporting documents (Ex. Marketing collateral, Award/recognitions, Photos of visible markers of LGBTQ inclusion, letter of support from NGLCC Local Affiliate Chamber, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Optional: Upload additional supporting documents (Ex. Marketing collateral, Award/recognitions, Photos of visible markers of LGBTQ inclusion, letter of support from NGLCC Local Affiliate Chamber, etc.)

No File Chosen

File uploads may not work on some mobile devices.

Optional: Submit a video to accompany your application (90 seconds MAXIMUM)

No File Chosen

File uploads may not work on some mobile devices.

If you are unable to upload your video within this form, you may send via WeTransfer, Dropbox, or Google Drive to GHgrant@nglcc.org

NGLCC & Grubhub Community Impact Grant Application

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