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
If You Answered "No" to the Tax Question Above, Please Explain Below.
If You Answered "Yes" to the Personal Bankruptcy Question Above, Please Explain Below.
If You Answered "Yes" to the Company Bankruptcy Question Above, Please Explain Below.
Statement of Public Benefit (please refer to program guidelines for details) *
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 *
If You Answered "Yes" to the Filed Suit Question Above, Please Explain Below.
If You Answered "Yes" to the Crime Question Above, Please Explain Below.
If You Answered "Yes" to the Law Suit Question Above, Please Explain Below.
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.
Title of Principal Representative of Applicant Business *