Intake Form - RIDC: Regional Industrial Development Corporation of Southwestern Pennsylvania

Intake Form

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Trade Name of Business*
Legal Name of Business*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Municipality*
County*
Date Business Established*
State Business Incorporated*
Tax ID Number (EIN)*
Does the Business operate outside of Pennsylvania*
- Yes
- No
Has the business received assistance from a Small Business Development Center or another economic service provider?*
- Yes
- No
Is the business located in an abandoned or underutilized building or site?*
- Yes
- No
Business Industry*
- Manufacturing
- Research & Development
- Developer
- Agriculture
- Construction
- Child Daycare
- Industrial
- Service Enterprise
- Energy
- Defense Conversion
- Hospitality
- Other
Legal Structure*
- Sole Proprietorship
- Limited Liability Company
- C-Corporation
- Partnership
- S-Corporation
LOAN REQUEST INFORMATION
Amount Requested*
Proposed Collateral*
Current Full Time Employees*
- Fewer than 100
- 101-250
- 251 or Greater
Current Part Time Employees*
- Fewer than 100
- 101-250
- 251 or Greater
Projected new Full Time Employees within 3 years of Financing*
- Less than 10
- 11-50
- 51 or Greater
Projected new Part Time Employees within 3 years of Financing*
- Less than 10
- 11-50
- 51 or Greater
Will jobs be lost without financing?*
- Yes
- No
Purpose of the loan*
- Land or Building Acquisitions
- Working Capital costs
- Construction and Renovation
- Machinery or Equipment
- Other, please explain:
Brief history of your organization, how has it grown, and how do you plan to grow with the financing of a PIDA loan.*
What benefit does your company offer the community?*
BUSINESS OWNERSHIP
List*
Provide names and percentages of ownership for each person owing at least 20% of the business. If no one person owns at least 20%, list the information for the five people who own the largest shares or hold the highest position.
Name Title/Position % of Business Owned Years with the Business
THIS IS FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT A LOAN APPLICATION. IMPORTANT! READ THIS BEFORE SIGNING
The collection of this data is not to be considered an application for a PIDA loan. Following receipt of a fully completed Intake Form, Regional Industrial Development Corporation of Southwestern Pennsylvania (“RIDC”) will determine, and the Applicant will be notified in writing, whether or not RIDC wishes to move forward with an Application for a PIDA Loan. SUBMISSION OF A LOAN APPLICATION IS NOT A GUARANTEE OF FUNDING BY PIDA. I verify that I am authorized to commit my organization and to submit this Intake Form on behalf of the organization. I certify that the above information is correct and that the statements made herein are true and correct to the best of my knowledge. I understand that this Intake Form or a subsequent Application may be disqualified if it does not contain all required information. I understand that all materials submitted as part of the Application are subject to disclosure. I acknowledge and agree that (1) RIDC has no obligation, and retains the sole discretion whether or not to proceed with a PIDA Loan Application and (2) submission of this Intake Form and any subsequent PIDA Loan Application, does not imply any promise of funding at any time.
NAME OF APPLICANT BUSINESS*
Signature*
Name*
First Last
Title*
Date*
MM slash DD slash YYYY
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