The Smalldon Group Intake Form
United States
Business Name
*
Date
-
Month
-
Day
Year
Date
Contact person (full name)
*
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Website
EIN
*
Is This Business Not For Profit?
*
Please Select
Yes
No
Number of Permanent Employees
*
Number of Part-Time Employees
*
Number of Casual Employees
*
Annual Revenue
*
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Assets and Funding
Please list your assets and their value
Asset
Value
Asset
Value
Asset
Value
Asset
Value
Asset
Value
Asset
Value
Asset
Value
Asset
Value
Total Project Cost
Notes : Anything Relative to Your Assets
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Other Funding Sources
Please list any other sources of funding and their approximate value
Source
Value Approx.
Source
Value Approx.
Source
Value Approx.
Source
Value Approx.
Source
Value Approx.
Source
Value Approx.
Source
Value Approx.
Source
Value Approx.
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Grant and Project Description
Grant Request and Purpose
*
Business / Project Description
*
When is the project expected to begin?
*
/
Month
/
Day
Year
Date
How long to complete?
*
e.g. 3 Months, 12 Months, 2 Years, etc.
Once completed, how will this project improve your business and create jobs, growth and prosperity for both your business and Americans?
*
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Additional Information
This section is optional, but we highly recommend you review and complete.
Is the Project/Program/Event targeting any of the following communities? Please check all that apply
Rural or Remote Area
Indigenous Communities
Ethno-Cultural Communities
Youth
Official-Language Minorities
Other
Does your organization have any specific "Designations" from a government agency or memberships? (Woman owned, black owned, veteran owned, Indigenous owned, disabled owned, etc.)
For individual applicants, do you have any specific "Designations" from a government agency or memberships that would be beneficial to this application, such as: Indigenous, Francophone, Disability, Youth aged 18 to 30, Gender, Nationality? (Specify)
Please add any additional information that may be valuable to your application.
Name
*
Date
/
Month
/
Day
Year
Date
Signature
*
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