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KITE Innovation Growth Fund Application

The information requested in this form will be used by Commerce to further understand your business venture. All company information provided in section I is subject to Kansas Open Records Act (KORA). Commerce will maintain strict confidentiality of all proprietary and confidential company and project information described in the other sections of the application form.

"*" indicates required fields

I. General Information

The information requested in this data sheet will be used by Commerce to further understand your business venture. All company information provided in section I is subject to Kansas Open Records Act (KORA). Commerce will maintain strict confidentiality of all proprietary and confidential company and project information described in the other sections of the application form.

Date*

Company Name*

Company Type (C, S, LLC)*

Founding Date*

State of Incorporation Date*

Company Address*

City*

State*

Zip*

County*

Company Phone*

Fax

Company Website Address

Referred By*

Federal Tax ID #*

NAICS Code*

(See www.naics.com for code)

Project Information

Project Description*

(8 word limit)

Requested Funds*

Matching Funds*

Current No. of Employees*

Economic Impact Information

Projected employees (five year plan)

Year*

Number*

Year*

Number*

Year*

Number*

Year*

Number*

Year*

Number*

II. President/CEO Background Check Information

Name*

Date of Birth*

Social Security Number*

Email*

Cell*

Business Phone

Please list previous counties, cities, states resided in during the last 10 years, including dates.*

Are there any significant legal, regulatory, or environmental issues pending against your company?*

Yes

If so, please describe

III. Business Plan

Please Attach Your Business Plan Here*

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Business Plan Outline

To Be Signed by President/CEO

Name*

Title*

Date*