Small Business Support Application

First Name: Middle Initial: Last Name:

Company Name:

Address: City: State: Zip:

Email: Phone:

About your business:
New business
Existing business
If existing, since: 		Current number of employees:
Current sales revenue, if any: $
Form of ownership:
Partnership Corporation Subchapter Sole Proprietor

Please check the types of projects in which you are requesting assistance:
Market Research and Analysis
Communications
Strategic Planning
Feasibility Study
 Marketing Plan Development
Business Plan Development
Technology Development
Other

Organization Description:

Who is your target market?

Estimate the investment to date in the business and the source of funds:
SOURCES AMOUNT
Loan$
Personal Resources$
Private Investors$
Government Grant or Contract$
Total$
Current YearYear 1Year 2Year 3Year 4
Assets
Liabilities
Equity
Sales
Net Income

Estimate the total number of employees (including principals) anticipated:

At the time of occupancy: Full-time: Part-time:

One year later: Full-time: Part-time:

Two years later: Full-time: Part-time:

Does the company currently utilize outside professional advisors (i.e., accountants, lawyers, etc.)?

Yes No

What are your core competencies?

Describe your project request in detail. Please be specific when describing the scope of your project.

Why do you wish to utilize these services? What do you expect to gain from the experience?

Please list any skills the consultants who work on your project should have:

Please share any other information that would be helpful in considering your application:

Check List:
Please make sure to include the following items:
completed application form provided
Resumes of all active principles
Business Plan, if available

I certify that the enclosed information is true and accurate to the best of my knowledge. I understand that by submitting this application, I am not guaranteed funding.

I Agree I Disagree

Submit materials by clicking the Submit button or send materials to: ASG, Inc.
Attention: Tracy Hartman
P.O. Box 1856
Muncie, IN 47308-1856

The funding for this project has been provided by the Indiana Department of Workforce Development.
Oversight is provided by the Eastern Indiana Regional Workforce Board.