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Census Access Kiosk Form

Business Name *

Kiosk Location Address *

What hours do you expect it will be available? * (e.g. M-F, 9 AM to 5 PM)

Contact Person *

Contact Phone *

Contact Email *

Will your Kiosk be open to the public? *

Yes

No

Are you able to staff a volunteer on April 1? *

Yes

No

Are you able to staff a volunteer for any other time period? *

Yes

No

If so, when?

General Description of Kiosk Location, if known at this time (e.g., main lobby or at a certain entrance) * (You have 2000 characters remaining)