LAKEWOOD UEZ INCENTIVE PROGRAMS APPLICATION
BUSINESS INFORMATION
COMPANY NAME (LEGAL)
*
Does the business have a DBA?
*
Yes
No
DOING BUSINESS AS
*
BUSINESS ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EIN # (no dashes or /)
*
BUSINESS PHONE NUMBER
*
Format: (000) 000-0000.
FAX / CELL / OTHER
EMAIL
*
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INCENTIVE PROGRAM SELECTION
INCENTIVE PROGRAM #
*
Please Select
1
2
3
↓↓Please see the program descriptions below↓↓
TOTAL GRANT AMOUNT REQUESTED
*
TOTAL GRANT AMOUNT REQUESTED 2
*
Program Name
Max Incentive Amount
1.
Small Busines Technology Grant
$5,000.00
2.
Employee retention Incentive
$1,500.00
(per emp, X3 $4500)
3.
Bank Fee Assistence Incentive
$5,000.00
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APPLICANT INFORMATION
Applicant Name
*
First Name
Last Name
Applicant Name (Combined)
*
First Last
Applicant Position/Title
*
Owner, Partner, etc.
Applicant Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Applicant Phone
*
Format: (000) 000-0000.
Applicant Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Applicant SSN
*
Applicant DOB
*
/
Month
/
Day
Year
Applicant percentage of ownership of the business
*
CO-APPLICANT INFORMATION
Co-Applicant Name
*
First Name
Last Name
Co-Applicant Name (combined)
*
First Last
Co-Applicant Position/ Title
*
Owner, Partner, etc.
Co-Applicant Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Co-Applicant Phone
*
Format: (000) 000-0000.
Co-Applicant Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Co-Applicant SSN
*
Co-Applicant DOB
*
/
Month
/
Day
Year
Co-Applicant percentage of ownership of the business
*
Total Percentage of Ownership
The total percentage of ownership does not equa
l 100%.
Please review the information submitted.
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SIGNATURES
Applicant Signature
*
Applicant Signature Date
*
/
Month
/
Day
Year
Date
Co-Applicant Signature
*
Co-Applicant Signature Date
*
/
Month
/
Day
Year
Date
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