Date Submitted

Applicant Name

Company

Company Address

City, State, and Zip Code

Project Company (if different)

Project Address (if different)

Project City, State, Zip (if different)

Applicant Email

Applicant Phone

Type of Business

Entity Type Entity Type S Corporation C Corporation Partnership LLC Sole Proprietor

Parcel Number (if known)

Square Footage

Year Built

Property Valuation

Insurance Company

Own or Lease? Own or Lease? Own Lease

List any related ownership partners, subsidiaries, proprietors, or business entities:

Is the building(s) subject to a mortgage or other secured interest? Is the building(s) subject to a mortgage or other secured interest? Yes No

If subject to mortgage, list financial institution and terms

If leased, does the building have tenants and sub-leases or is it leased to another related entity? If leased, does the building have tenants and sub-leases or is it leased to another related entity? Yes No

If leased, list names and lease terms

Has an energy audit been completed on your building or facility? Has an energy audit been completed on your building or facility? Yes No

Project Description

Financial Impact Expected

Please describe how this will impact employment or payroll numbers