Form Center

2. Restaurants Open for Business
   If you are an owner, manager, or authorized representative of a restaurant or food business in the City of Jurupa Valley that is currently offering delivery, drive-though, or carry-out service during the COVID-19 pandemic, please submit this form. We will use the information that you submit to promote local restaurants and food business on the City's website. Contact us at City Hall if you have any questions (951) 332-6464.
4. Business Representative Name*
   First and last name of owner, manager, or authorized representative submitting this information on behalf of the business.
6. Business Representative Phone Number*
   Phone number of the individual submitting this form for City Hall use only
8. Relation to the Business*
   -- Select One --OwnerManagerAuthorized RepresentativeOther

   What is your relation to the business?
10. Business Name*
    Name/operating name of restaurant of food service business
12. Business Address (Number & Street)*
    Operating address of restaurant or food service business
14. Business Phone Number*
    Business phone number available to the public
16. How are you providing food?

    1. Delivery
    2. Carry-out
    3. Drive-through
    4. Other

    Check all that apply
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field