Author: McCamey EDC

APPLICANT INFORMATION:
Name of Business:_______________________________________________________
Street Address:________________________________County:___________________
City/State/Zip_________________________________Telephone:_________________
Date Established:______________________________ Tax I.D.#__________________
___New Business ___Existing Business
Type of Business (Product or Service):_______________________________________
Organizational Structure: (check one)
__Corporation __S Corpotation __Partnership __Propriertorship __LLC
Number of Employees: Present:____________________________________________
Name of Individual Completing this Form:____________________________________
Project Location(if defferent from above):_____________________________________
____________________________________________________________________________
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II. OWNERSHIP INFORMATION: Provide the following information on the owner(s) of the busi ness: Is at least 51% of the business owned by those who are either citizens of the US or reside in the US after being legally admitted for permanent residence? __Yes __No

INSTRUCTIONS:
Complete all portions of the application and attach requested exhibits.
NOTE: Not all business and/or projects qualify for financing. Prior to completing this form, potential applicants need to contact MEDC Office to determine eligibility

APPLICATION FOR FINANCING

Name	Address	%Ownership	Annual Compensation

III. SOURCES AND USES OF PROJECTS FUNDS
_____________________________________________________________________________
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IV. REFERENCES (Banking & Trade)
1. Name:_______________________________ Address:_____________________
Contact Person:_______________________ Telephone#__________________
2. Name:_______________________________ Address:____________________
Contact Person:________________________ Telephone#__________________
3. Name:_______________________________ Address:_____________________
Contact Person:_______________________ Telephone#___________________
_____________________________________________________________________________
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V. EXHIBITS (all exhibits must be signed and dated)
______1. A brief description of the business and project being financed. Exhibit A.
_____ 2. A year schedule of jobs that will be created or saved as a result of this Financing. In the case of “saved” jobs, provide justification that the job would be lost without MEDC RL assistance. Exhibit B.
______3. Most recent financial statements or tax return. Exhibit C
______4. A current balance sheet projected operating statement with notes of explanation. Exhibit D.
______5. Pro-Forma balance sheet and projected operating statement with notes of explanation. Exhibit E.

		Sources
USES	ED-RLF	Private / Lender	EQUITY	OTHER	TOTAL / USES
Land Acquisition
Land Improvement
Building/Purchase
Building/Construction
Building/Renovation
Working Capital
Equipment/Machinery
Other
Total Sources

______6. Insurance on collateral, insurance on business & equipment, and workman's comp. Exhibit F.
______7. Preliminary plans and specifications covering new construction, and an itemized list of machinery and equipment to be purchased. Exhibit G.
______8. A list of collateral to be offered as security for the MEDC Revolving Loan (Note: An independent appraisal may be required.). Exhibit H.
______9. Environmental Questionnaire (If applicable). 1940-20 Exhibit I.
_____10. Supporting documentation such as credit reports, contracts, legal description, copies of leases, Attach as appropriate. Exhibit J.
____________________________________________________________________________________
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VI. GENERAL CERTIFICATION
Applicant: The undersigned certifies that he/she is the ____________________________(title) of the applicant business applying for financing from MEDC Revolving Loan Program, that he/she I is familiar with the records of the borrower and contents of this application, and that he/she au- thorized to submit and sign the application. The information contained in this application, include- ing all exhibits, is to the best knowledge of the undersigned, complete and accurate and presents fairly the condition of the applicant and project accurately its intended operations for the period set forth in this application.
Applicant(typed): ____________________________________
Signature: ____________________________________
Date: ____________________________________
____________________________________________________________________________________
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VII. MEDC REVOLVING LOAN FUND PROGRAM CERTIFICATION:
The purpose of the RLF is to help fund small businesses that plan to relocate or open business in the City of McCamey. The RLF also finances projects that retain jobs. The ratio is 1 job created or retained per $10,000 borrowed. The lender reserves the right to recall the loan if these require- ments are not met.
Applicant(typed): ___________________________________
Signature: ___________________________________
Date: ___________________________________
____________________________________________________________________________________
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VIII. APPLICATION FEE AND CREDIT CHECK AUTHORIZATION
I hereby authorize the MEDC to make inquiries as to credit worthiness in whatever ways neces sary to meet the requirements of the Revolving Loan Fund Program. An application fee of $100 (one hundred dollars) must be submitted when this application is returned to the MEDC office.
Applicant (typed):_______________________ Co-Applicant (typed)____________________ Signature/Date:_________________________ Signature/Date:________________________
DOB/SS#: ____________________________ DOB/SS#:_____________________________
Business Ownership Classification:(enter all that apply)
1. White____ 2. Black____ 3. American Indian/Alaskan Native ___4. Asian/Pacific Islander____
5. Hispanic ____ 6. Non-Hispanic____ 7.Female______ 8. Male_______ 9. Veteran______