Financing Application Form

Comments

This field is for validation purposes and should be left unchanged.

Company Summary

Company Name

Type of Business

Date Founded

Date Inc

State Organized

(If not sole proprietor)

Type of Business

Proprietorship

Partnership

C Corporation

S Corporation

Other

NAICS

Federal EIN

DUNS Number

Description of the Product or Primary Business of the Company(Required)

Contact Person(Required)

Name Title

Telephone(Required)

Telephone

Cell Phone(Required)

Cell Phone

Fax

Email(Required)

Email

Are you a U.S. citizen or have legal status?

Yes

No

If no, please provide details:

Do you have a website?

Yes

No

If yes, list:

Would you like your business to be identified as (51% or more of ownership is):

Woman-Owned

Minority-Owned

Veteran-Owned

LGBTQIA+ Owned

Person w/ a Disability Owned

Principals/Owners(Required)

Name

Title/Position

SSN/Fed ID #

% Owned

Years Experience

Personal Income

Household Income/# of People in Home

Attach Resumes of Principals/Owners

Upload resumes in PDF or Microsoft Word Document format.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 49 MB.

Affiliated Companies

Function of Affiliates

Are you or any company that you own or have previously owned ever filed for bankruptcy?(Required)

Yes

No

Are you or your business involved in any pending or prior lawsuits?(Required)

Yes

No

Have you ever been convicted of a felony?(Required)

Yes

No

Describe, include date:(Required)

Are all of your taxes current?(Required)

Yes

No

If no, describe:(Required)

Do you have any judgements against you or your business?(Required)

Yes

No

If yes, describe:(Required)

Locations

Mailing Address(Required)

*Correspondence to be sent

Street Address Address Line 2 City State ZIP Code

County(Required)

County

Municipality(Required)

Municipality

Political Districts

PA House

PA Senate

US Congress

Site Address(Required)

*Site where project funds are to be utilized (if different from above)

Street Address Address Line 2 City State ZIP Code

County(Required)

County

Municipality(Required)

Municipality

Political Districts

PA House

PA Senate

US Congress

Is the site where the funds being utilized:

Enterprise Zone

Brownfield

Act 47 Community

Keystone Opportunity Zone

Prime Agricultural Area

Uses PA Port

KIZ

Facility Data

Existing Facility

Facility Size (Sq. Ft.)

Acreage

Ownership

Owned

Leased

Purchase Price

Purchase Year

Appraised Value

Appraised Year

Outstanding Mortgage Balance

Annual Mortgage Payment

Owner

Owner's Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Lease Expiration Date

Annual Lease Payments

New Facility

Facility Size (Sq. Ft.)

Acreage

Expansion/Replacement

Expansion

Replacement

Company to occupy entire space?

Yes

No

Appraised Value

Contact Information

Legal Contact Information

Company

Address

Contact Name

Phone

Email

Accountant Contact Information

Company

Address

Contact Name

Phone

Email

Insurance Contact Information

Company

Address

Contact Name

Phone

Email

Marketing Information

Major Customers

Location (City & State)

% of Sales

Calculate percentage of sales from the last fiscal year or 1st year projected.

Major Suppliers

Location (City & State)

Major Competitors

Location (City & State)

Company Geographic Marketing Area

Financing Project

Please provide the total project costs for each of the following. Include all costs, including JARI costs. If no cost, please put 0.

Land Acquisition(Required)

Building Acquisition(Required)

Building Construction(Required)

Leasehold Improvements(Required)

Machinery and Equipment(Required)

Working Capital(Required)

Working Captial

Please specify uses of working capital.

Total(Required)

Have you been turned down for financing by another source?(Required)

Yes

No

If yes, state source:(Required)

Do you have another source of funds?(Required)

Yes

No

If yes, provide approved commitment letter.

Accepted file types: pdf, doc, Max. file size: 49 MB.

Job Creation & Retention

Please enter the total number of existing employees, as well as the number of expected employees over the next several years.

Existing Employees

Full-Time(Required)

Part-Time(Required)

Expected Employees - Projected 1st Year

Full-Time(Required)

Part-Time(Required)

Expected Employees - Projected 3rd Year

Full-Time(Required)

Part-Time(Required)

Authorization

Everything I/we have stated in the application is correct to the best of my/our knowledge. I/we understand that to knowingly make any false statements concerning any of the above facts or information contained in this application is a Federal Crime punishable by fine or imprisonment, or both, as applicable under the provisions of Title, 18, United States Code, Section 1014. The undersigned further warrants that a Bankruptcy processing is neither presently in progress or anticipated.

I/we authorize you to gather credit information about me/us and to check all information contained in this application.

Please provide a check payable to JARI in the amount of $35 to cover the cost of the credit check and the background check for the individual listed above. This fee is non-refundable and due at signing.

Authorized Representative(Required)

By typing my name above, I am electronically signing this form.

Title

Date(Required)

Company Summary

Locations

Facility Data

Existing Facility

New Facility

Contact Information

Legal Contact Information

Accountant Contact Information

Insurance Contact Information

Marketing Information

Financing Project

Job Creation & Retention

Existing Employees

Expected Employees - Projected 1st Year

Expected Employees - Projected 3rd Year

Authorization

Contact Us

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