Application Checklist: (Please ensure completion of all four checkboxes before application submission)

SIEC Award Application Form

Executive Summary (not to exceed 3 pages) (see SIEC Executive Summary Guidelines)

Entrepreneurial Questions (200 word response per question maximum):

1. Describe the proposed business milestone and how the SIEC award along with your match will help you accomplish this growth.

2. Describe the experience, skills, and abilities you and your management team possesses to make you venture successful.

3. Decribe your businesses competitive advantage.

Signed Certifications Page - To be signed by applicant at initial meeting

Amount of Award Funding Requested ($5,000 maximum with dollar for dollar match from applicant): $

Business Name:

Business Address: Check here if home address

City:

State:

Zip Code:

County:

Business Phone:

Business website:

Primary Contact and Authorized Signatory:

Last Name:

First Name:

Middle Initial:

Phone:

Fax:

Cell:

Email:

Designated award administrator for the Awardee: Check here if same as primary

Name:

Phone:

Email:

Please check one: New Business Venture Existing Business Venture

Date Established:

Proposed / Existing Legal Structure:

Sole Proprietorship
Partnership
C Corp
S Corp
LLP
LLC

For reporting purposes, is your business:

Women Owned
Minority Owned
Classification

Secretary of State File Number:

Check here if not applicable

List the number of business locations you currently have within Illinois:

List all persons who have an ownership in this business greater than 5% and their % of ownership:

Employee Information:

Total company employment:

Total Illinois Employment:

Current number of Full Time Equivalents (FTEs) at business address listed above:

What is the principal's current employment status and source of income? (check all that apply)

Provide the following historical and projected data for the business:

*(Earnings Before Interest Taxes Depreciation and Amortization)

List the proposed Contracted Service Provider(s) for the project: Check here if undetermined at the time

Business Name:

Address:

Phone:

Website:

List the source and amount of match for the award: (Match must equal the SIEC award amount dollar for dollar)

$ Personal Cash Investment

$ Family and Friends Investment

$ Instititutional Loan

$ Other (Specify )

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