Warren Microenterprise Grant Application

Please complete the Demographic information for each owner.

Personal Information

BUSINESS OWNER TWO
Business Owner's Name (authorized signer) *

First Name Last Name
Business Owner's Physical Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Business Owner's Email Address *
example@example.com
Business Phone Number *
Please enter a valid phone number.
Business Owner's Cell Number
Please enter a valid phone number.
Does the business owner, or a member of the business owner's immediate family, currently work for the towns of Warren or hold a position on a town board or committee (potential conflict of interest issues)? *

YES NO
If yes, please indicate your position: position in the town of: town .
Person completing this form:name* PHONE:phone*
EMAIL:email*

Please complete the Demographic information for each owner.

Personal Information

BUSINESS OWNER TWO
Business Owner 2 Name

First Name Last Name
Business Owner 2 Physical Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Business Owner 2 Email Address
example@example.com
Business Owner 2 Phone Number
Please enter a valid phone number.
Business Owner 2 Cell Number
Please enter a valid phone number.
Business Owner 2: Does the business owner, or a member of the business owner's immediate family, currently work for the town of Spencer or hold a position on a town board or committee (potential conflict of interest issues)?

YES NO
If yes, please indicate your position: position in the town of: town .
Person completing this form:name PHONE:phone
EMAIL:email

Required Certification
I/we name certify that the information on this application and in attached documents is true and accurate to the best of my/our knowledge and is provided for the purpose of obtaining a grant. I/we authorize Quaboag Valley CDC to make inquiries, as needed, to verify the accuracy of this information.

By submitting this application, I/we agree to provide regular progress reports at least quarterly through 2021 and to follow all rules governing this funding under the CARES Act of 2020.

I/we understand that the program requires the funds to be used appropriately and as discussed or they may be retracted.
Signature *

Clear
Title/position *
Date *

Month Day Year
Date
Signature

Clear
Title/position
Date

Month Day Year
Date
Signature

Clear
Title/position
Date

Month Day Year
Date
Thank You! In order for your application to be complete, please include:

This form completed and signed Income Eligibility Form Copies of your most recent business and personal federal tax returns Copies of your forms 941 for the past year, if you have employees Copies of state licenses/registrations. Documentation/proof of income loss due to Covid-19. Copy of alternative source of funding and terms, if applicable. Duplication of Benefits Form
*Note: Additional documentation may be required in order to fully assess your business and its needs.
Please upload and attach any additional information

Cancel of
Please verify before submitting *
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Microenterprise Grant Application