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Natural Disaster Assistance Project
First Name
*
Last Name
*
Company Name
*
ABN Number
*
Contact Number
*
Email Address
*
Street Address
*
Town/Suburb
*
State
*
Select One
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Post Code
*
Industry Sector
Please select below the industry sector(s) you are involved in - you may select multiple sectors.
Agriculture, forestry and fishing
Mining
Manufacturing
Construction
Wholesale trade
Retail trade
Accommodation, cafes, and restaurants
Transport and storage
Communication services
Finance and insurance
Property and business services
Education
Health and community services
Cultural and recreational services
Personal and other services
Electricity gas and water supply
Other (please specify)
Run By
*
Select One
Men
Women
Both
No. of Employees
*
Impact type
*
Select One
My premises directly affected (property damage, disruption to utilities, etc.)
Supplier services impacted, reduced number of visitors/sales/demand
My staff directly affected (insufficient employees to run business)
Business not in affected zones but impacted by flow on affects
Please Explain
*
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