Form Center

City of Norfolk Capital Access Program Application

2. Department of Economic Development
   999 Waterside Drive, Suite 2430, Norfolk, VA 23510
   Phone: (757) -664-4338 Fax: 757-441-2910

4. • Application must be completely filled in for consideration
   • Where applicable, please indicate N/A.
   • A personal financial statement from a financial institution is acceptable IF it is within the last six months.
   • Please submit remaining documents with completed application

6. Amount Requested:*

7. What will funds be used for: *

9. BUSINESS APPLICANT/CO-SIGNER INFORMATION

11. Company Name:*

12. Federal Tax ID:*

13. Type of Business:*
    -- Select One --ABC

15. Applicant is:
    -- Select One --Sole ProprietorshipPartnershipLLCS-CorporationCorporationNot incorporated yet

16. State:*
    -- Select One --ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

17. Years in business

18. # Employees

20. Business Address*

22. City

23. State

24. Zip

26. Phone Number:*

27. Website Address:*

29. Principal Applicant Name:*

30. Title:*

32. Principal Phone Number:*

33. Fax:

34. Email:*

36. PROJECT INFORMATION

38. Project Description:

40. REFERENCES (Please put N/A if you do not have a contact)

42. Bank Name:*

43. Account Officer:*

44. Phone Number:*

45. Email Address:*

47. Bank Name:*

48. Account Officer:*

49. Phone Number:*

50. Email Address:*

52. Accountant:*

53. Firm Name:*

54. Phone Number:*

55. Email Address:*

57. Attorney:*

58. Firm Name:*

59. Phone Number:*

60. Email Address:*

62. COMPANY OWNERSHIP (IF UNINCORPORATED)

64. Name:

65. Title:

66. % of Ownership

68. Name:

69. Title:

70. % of Ownership

72. Name:

73. Title:

74. % of Ownership

76. Name:

77. Title

78. % of Ownership

80. AFFILIATED BUSINESSES (List any other business owned by any principal with 20% or more ownership in the company)

82. Business Name:

83. Owner:

84. % of Ownership

86. Business Name:

87. Ownership:

88. % of Ownership

90. Business Name:

91. Ownership:

92. % of Ownership

94. Business Name:

95. Ownership:

96. % of Ownership

98. Use of Funds

100. Real Estate (land and building)

101. Professional services expense

102. License & Fees

104. New construction/expansion/renovation

105. Acquisition/repair of machinery and equipment

107. Inventory

108. Miscellaneous expenses

109. Working Capital

111. You certify that the information provided in this application is true and correct. This application does not obligate the City of Norfolk nor the Economic Development Authority of the City of Norfolk to make any grant or loan. The approval/denial decision will partly be based on the economic impact of the project on the City of Norfolk. This can but is not limited to job creation and benefit to low-moderate income residents.

113. Signature

114. Title

115. Date
     Date

Leave This Blank:


116. 1. Receive an email copy of this form.
117. Email address

     This field is not part of the form submission.

118. Submit

* indicates a required field