"Arkansas Science and Technology Authority Investment Application" - Arkansas

Arkansas Science and Technology Authority Investment Application is a legal document that was released by the Arkansas Department of Commerce - a government authority operating within Arkansas.

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Arkansas Science and Technology Authority
Investment Application
Amout
This application is for:
Seed Capital Investment Program *
Technology Development Program *
* Indicate the program you are applying for by placing the desired investment amount in the appropriate box.
Date:
Legal Name of Applicant:
Federal Tax ID :
(Do not list Social Security Numbers)
NAICS Code
NAICS Title
(http://www.census.gov/eos/www/naics/)
Type of Company:
Sub-S
C-Corp
LLC
Other
Date Company Organized:
Date Company Formed/Incorporated:
State in which Company Formed:
Location of Primary Business Activity:
Address: (Include Parent Company, If
Applicable)
Street
City
State
Zip
Contact Person(s):
Phone:
Fax:
E-mail Address:
Attorney:
Phone:
Fax:
E-mail Address:
Accountant:
Phone:
Fax:
E-mail Address:
Officers and Key Personnel
Name
Position
Age
Percent Ownership
Arkansas Science and Technology Authority
Investment Application
Amout
This application is for:
Seed Capital Investment Program *
Technology Development Program *
* Indicate the program you are applying for by placing the desired investment amount in the appropriate box.
Date:
Legal Name of Applicant:
Federal Tax ID :
(Do not list Social Security Numbers)
NAICS Code
NAICS Title
(http://www.census.gov/eos/www/naics/)
Type of Company:
Sub-S
C-Corp
LLC
Other
Date Company Organized:
Date Company Formed/Incorporated:
State in which Company Formed:
Location of Primary Business Activity:
Address: (Include Parent Company, If
Applicable)
Street
City
State
Zip
Contact Person(s):
Phone:
Fax:
E-mail Address:
Attorney:
Phone:
Fax:
E-mail Address:
Accountant:
Phone:
Fax:
E-mail Address:
Officers and Key Personnel
Name
Position
Age
Percent Ownership
Arkansas Science and Technology Authority
Investment Application
Description of Current Ownership (name, percentage of ownership, classes, capital paid in, shares authorized, shares
outstanding)
Amount, Timing & Use of State Funds (Explain the use of funds listed below in your business plan or attach an explaination)
Amount, Timing & Use of State Funds
Year 1
Year 2
Year 3
Year 4
Year 5
Acquisition
Land Purchase
Construction/Renovation
Machinery/Equipment
Installation of M/E
Inventory
Refinancing Existing Debt
Start-up costs
Working Capital
Other (specify)
Total $
-
$
-
$
-
$
-
$
-
Amount, Timing & Use of Matching Private Funds
Amount, Timing & Use of Matching Private Funds (Indicate whether Equity or Debt)
Year 1
Year 2
Year 3
Year 4
Year 5
Acquisition
E/D?
E/D?
E/D?
E/D?
E/D?
Land Purchase
E/D?
E/D?
E/D?
E/D?
E/D?
Construction/Renovation
E/D?
E/D?
E/D?
E/D?
E/D?
Machinery/Equipment
E/D?
E/D?
E/D?
E/D?
E/D?
Installation of M/E
E/D?
E/D?
E/D?
E/D?
E/D?
Inventory
E/D?
E/D?
E/D?
E/D?
E/D?
Refinancing Existing Debt
E/D?
E/D?
E/D?
E/D?
E/D?
Start-up costs
E/D?
E/D?
E/D?
E/D?
E/D?
Working Capital
E/D?
E/D?
E/D?
E/D?
E/D?
Other (specify)
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
E/D?
Total $
-
$
-
$
-
$
-
$
-
Schedule of Debt
(Include any Working
Capital Financing)
Lender
Original Amount
Current Bal.
Interest Rate
Collateral
Arkansas Science and Technology Authority
Investment Application
Brief Description of Business Enterprise
Brief Description of Business's Current Technology and Level of Development
Economic Impact
Anticipated Job Creation in Arkansas
Percentage of
Avg. Pay per
Number of Jobs
Location
Total Jobs
Job Description
Hour
Created
(County)
Created
Secretarial
Unskilled
Semi-Skilled
Skilled
Professional
Management
Other (specify)
Total Jobs
Average Wages
Created
Avg. Pay per
(at this site)
(overall)
Job Creation:
Hour
Present Employment:
Number of jobs created by this project:
(within 24
months)
List Other Anticipated Economic Benefits
Below:
(This can include Arkansas vendors & customers or any other Arkansas business's or individuals that will benefit because of your
business)
Necessity of State Investments &/or Tax Incentives: (Explain why State assistance is necessary for this project to succeed.)
Necessity of State Investments: (Explain why the enterprise has been unable to secure sufficient capital from traditional capital sources
on terms that would enhance the success of the enterprise?)
Is your project or operation subject to any state or federal health, environmental and/or occupational
safety regulations that require approval, permit, license, testing or regular inspection?
____YES
____NO
If YES, please specify:
Arkansas Science and Technology Authority
Investment Application
Is anyone associated with the Arkansas Risk Capital Matching Fund, the Arkansas Development
Finance Authority, the Arkansas Science and Technology Authority, the Arkansas Economic
Development Commission or the Arkansas Department of Finance and Administration involved with
your enterprise in any manner?
____YES
____NO
If YES, please specify:
Please Attach the Following Information if this application is for the Seed Capital Investment Program.
1 Detailed Business Plan
(This should include the background, history and business of the enterprise. It should also include a detailed description of the marketing
plan, the operations plan, the management team, financial statements and projections, and the products and technology involved.)
Detailed Uses and Sources of Funds (This can be included within the Business Plan if desired)
2
3
If company has been in business for three years provide audited annual financial statements for last three years. If statements are not
audited, please have an authorized officer sign each page and include federal income tax returns. Most recent interim financial statement.
4
Resumes for key executive management of the company.
5
Five years projected income statement, cash flow statement, balance sheet and assumptions used in preparation.
6
List Board of Directors & Advisory Board Members
7
List any other State Investments or State Tax Incentives the company has received.
Pledge
To the best of our knowledge, the data and information contained in this application and in any attached documents are true and correct.
We realize that additional information may be requested for evaluation purposes. We agree to comply with all applicable federal and state
laws and regulations. Print the Form, Sign & Date
Title and Signature of Authorized Individual(s)
Date
CONFIDENTIAL INFORMATION AGREEMENT
The Arkansas Science and Technology Authority (the "Authority") has established its Seed Capital Investment Program (the "Program")
to provide financial assistance to technology-based companies located in Arkansas. In order to evaluate your application for funding
under the Program, it is necessary to ask for information that your company may consider confidential. The Authority will utilize the
information contained in the application only to evaluate the merits of your proposal, and will exercise diligence in preventing the
disclosure of information that you designate as confidential.
As you complete the application, please clearly mark as "confidential" any sections or items that you reasonably believe would cause
competitive injury to your company if disclosed to parties outside of your company or the Authority. We ask that you exercise restraint and
discretion in requesting that information be held confidential. Please bear in mind that the Authority is subject to the Arkansas Freedom of
Information Act, Arkansas Statutes Annotated Section 12-2801 et seq. (the "Act"). Under the terms of the Act, the files of the Authority are
generally open to the public, except for such "files which, if disclosed, would give advantage to competitors..." The Authority will make
every effort to prevent the public disclosure of information that you designate as confidential, but cannot assure you that information not
fitting within the exception to the Act will be free from public scrutiny.
In any event, the Authority will not take special steps to prevent the public release of: (1) information that is in the public domain at the
time of disclosure by you to the Authority, or which later enters the public domain or becomes common knowledge; (2) information that the
Authority has in its possession at the time of disclosure by you or information that is developed independently by the Authority; (3)
information that the Authority obtains from a third party; or (4) information that you disclose to a third party without imposing a requirement
of confidentiality. The Authority may submit parts or all of your application to third party consultants for their evaluation. These consultants
may be asked to review those materials that you have designated as confidential. In such cases, however, the Authority will require the
consultants to sign nondisclosure agreements prior to their review of the confidential portions of your application. Please confirm your
acceptance of this agreement by signing and returning to the Authority with your application and business plan. Print the Form, Sign &
Date
Title and Signature of Authorized Individuals)
Date
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