Business Name (Exact Legal Name) * Business Type * Full, Legal Name of Principal Representative of Applicant Business * Title of Principal Representative * Email of Principal Representative * Full, Legal Name of Alternative Business Contact Title of Alternative Business Contact Email of Alternative Business Contact Current Physical Address of Applicant Business * Proposed New Physical Address of Applicant Business (If Applicable) Are All the Principals of the Business U.S. Citizens or Legal Residents? * If Partnership, Please Check One of the Following Are All Taxes (Business and Personal) Current? * If You Answered "No" to the Tax Question Above, Please Explain Below. Have Any of the Principals Ever Filed for Personal Bankruptcy? * If You Answered "Yes" to the Personal Bankruptcy Question Above, Please Explain Below. Has the Present Company, or Any Company Where Any of the Current Company Principals Are or Have Been a Principal, Ever Filed Bankruptcy? * If You Answered "Yes" to the Company Bankruptcy Question Above, Please Explain Below. Is The Business Woman-, Veteran,-, or Minority-Owned? (Check All That Apply and Attached Certifications, if any.) * Select How the Business Serves a Public Benefit and Meets the Impact Fund Criteria (Check All That Apply). * Statement of Public Benefit (please refer to program guidelines for details) * Select How You Intend to Use the Impact Funds (Check All That Apply). * Describe How the Funds will be Used. * Number of City of Rockville Residents Currently Employed * Number of Hard-to-place City of Rockville Residents Employed * Describe Your Strategy and Plan to Employ Hard-to-place Rockville Residents * Has The Company or Any of the Principals Ever Filed Suit Against The City of Rockville? * If You Answered "Yes" to the Filed Suit Question Above, Please Explain Below. Have Any of the Principals of the Company Ever Been Charged Or Convicted of a Crime Other Than a Misdemeanor? * If You Answered "Yes" to the Crime Question Above, Please Explain Below. Are there any Law Suits threatened, in force, or pending Against The Business or any of the Business Principals/Owners? * If You Answered "Yes" to the Law Suit Question Above, Please Explain Below. Has the Applicant Applied for or Received Any Government Grants Or Loans (Other than the Rockville Small Business Impact Fund)? * If you answered "Yes," please provide the following information for each: Lender's Name, Amount, Date of Award, Collateral Pledged, and Attach a copy of the Commitment Letter. Certification & Acknowledgement * Funding is subject to the availability of funds. Funds will be disbursed based on an agreed-upon schedule. All applications are subject to the review and approval by the Rockville Small Business Impact Fund application review committee. If REDI approves this application, the Applicant will use reasonable efforts to consider, for all available positions, qualified City of Rockville residents who are either unemployed or under-employed. According to the Privacy Act of 1974, financial and proprietary information submitted with an application for a loan will be kept strictly confidential. Requests for information by third parties will be honored with the consent of the applicant. All information in this application, and any exhibits or attachments, is true and complete to the best of my/our knowledge. Principals of applicant business are not employees of Rockville Economic Development, Inc. or the City of Rockville, and are not elected or appointed officials of the City of Rockville. Applicant company and its principals are not delinquent or in default on federal, state or local taxes, or any existing private or publicly financing loan. Funds will not be used for: start-up capital (except for operating expenses and security deposits), refinancing of existing debts (including leveraged buy-outs); acquiring real estate; or distributions or payment to the owners, partners, shareholders, or beneficiaries of the Applicant and members of their families. Applicant and applicant business agree to comply with all applicable local, state and federal laws and to keep such records as may be required by REDI in connection with the Rockville Small Business Impact Fund. Due to the scope and variation in applicant types, additional information may be requested throughout the application process. Applications submitted without all required documentation may not be processed until full documentation is received. The applicant(s) and the small business concern have read all of the above and agree to abide by the same, as evidenced by the electronic signature below of the Principal Representative of Applicant Business.
BY CHECKING THESE BOXES AND SUBMITTING THIS ONLINE APPLICATION, APPLICANT HEREBY AGREES TO THE STATEMENTS. ALL BOXES MUST BE CHECKED FOR APPLICATION TO BE CONSIDERED COMPLETE.
Title of Principal Representative of Applicant Business * Date of Electronic Signature *