Form Center

Keep Safe Russellville Business Pledge

2. Keep Safe Russellville Business Pledge
   
4. Business Information
6. Business Name*
8. Business Address*
10. City*
11. State*
12. Zip Code*
14. Business Phone Number*
16. Business Website Link
17. Please Choose One

    1. Website
    2. Facebook

    Check the box on your choice for link destination.
19. Business Facebook Link
21. Business Category*
    -- Select One --Accounting & Tax ServicesArts, Culture & EntertainmentAuto Sales & ServiceBanking & FinanceBusiness ServicesCommunity OrganizationsDentists & OrthodontistsEducationHealth & WellnessHealth CareHome ImprovementInsuranceInternet & Web ServicesLegal ServicesLodging & TravelMarketing & AdvertisingNews & MediaPet ServicesProfessional ServicesReal EstateReligious/Faith-Based OrganizationsRestaurants & NightlifeShopping & RetailSports & RecreationTransportationUtilitiesWedding, Events & MeetingOther
23. By signing this form and agreeing to participate in the pledge to Keep Safe Russellville, I agree and acknowledge that I will abide by all executive orders issued by the Governor of the State of Arkansas and directives from the Arkansas Department of Health related to Covid-19 and my respective business. The business also agrees to abide by any newly issued executive orders or health care directives issued after the signing of this document related to Covid-19 and my respective business. By agreeing to this pledge, I agree to any inspections by the City of Russellville to assure compliance with its continued participation in the Keep Safe Russellville program. I agree and acknowledge that the City of Russellville enjoys certain immunities under Ark. Code Ann. § 21-9-301. Further, I agree and acknowledge that any non-compliance with any executive orders issued by the Governor or any health care directives issued by the Arkansas Department of Health will cause my business to be terminated from the Keep Safe Russellville program and its name will be removed from any acknowledgements in the program.
25. Signature*
26. Date*
    Date
28. Contact Information
30. Contact Name*
31. Contact Phone Number*
33. Contact Email*
35. Please Upload a business logo or photo for promotional purposes below OR you may email your images to James Hodge, Assistant IT Director, at jhodge@rsvlar.org
37. Business Logo Upload
39. Business Photo Upload
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field