Carbon County Industrial Development Authority (CCIDA) and Carbon County Chamber & Economic Development (CCEDC)Small Business Loan Program

General Information

Please fill out the information below to the best of your ability.

Legal Name of Company *

Legal Name of Applicant/Representative *

Date Company was founded *

Date Incorporated (if Inc.)

Brief history of the Company *

Product/Business Description *

Ownership *

Please list all Officers & Management (Attach Resumes) *

Upload Resumes (.doc, .docx, .pdf accepted)

If you cannot upload documents, please email them directly to jsoto@carboncountychamber.org with a reference to this application.

Please identify all Parent, Subsidiary and Affiliated Companies including the Location, Number of Employees, and Ownership Breakdown (%) *

If necessary, please send full list to jsoto@carboncountychamber.org with a reference to this application.

CCIDA/CCEDC LOAN APPLICATION PROJECT DESCRIPTION

Describe the real estate portion of the project (if applicable - if no real estate portion, please type "N/A") *

Real Estate COST (if applicable - if no real estate, please type "N/A") *

Describe the machinery & equipment to be acquired (if applicable - if no machinery/equipment, please type "N/A") *

Machinery & Equipment COST (if applicable - if no machinery/equipment, please type "N/A") *

Total project cost *

CCIDA/CCEDC LOAN APPLICATION ECONOMIC IMPACT

Legal Name of Company *

FEIN *

Size of Project (Sq. Ft.) or Size of Site (Acres) *

Total current full-time employees – include parent, subsidiaries, and affiliates - in Pennsylvania *

Total current full-time employees – include parent, subsidiaries, and affiliates - Worldwide (inc. Pennsylvania) *

Total Employment (this site only) *

Annual Payroll (this site only) *

Average Annual wage (this site only) *

Total Employment - Projected NEW in 1 Year (this site only) *

Projected New Annual Payroll - 1 Year (this site only) *

Projected New Average Annual wage - 1 Year (this site only) *

Total Employment - Projected NEW in 3 Years (this site only) *

Projected New Annual Payroll - 3 Years (this site only) *

Projected New Average Annual wage - 3 Years (this site only) *

Estimated Sales (1-3 Years)

Please indicate your estimated increase in sales over the next 1, 2, and 3 Years.

Estimated Increase in Sales (1 Year) *

Estimated Increase in Sales (2 Years) *

Estimated Increase in Sales (3 Years) *

Estimated Increase in Out-of-State Sales (1 Year) *

Estimated Increase in Out-of-State Sales (2 Years) *

Estimated Increase in Out-of-State Sales (3 Years) *

In-state sales increase captured from out-of-state competition (1 Year) *

In-state sales increase captured from out-of-state competition (2 Years) *

In-state sales increase captured from out-of-state competition (3 Years) *

CCIDA/CCEDC LOAN APPLICATION STATEMENT OF CRIMINAL HISTORY

(To be completed and signed by each officer and major stockholder)

Please click the link below to download the CCIDA/CCEDC Loan Application Statement of Criminal History and have each officer and stockholder complete. Please submit all completed forms to jsoto@carboncountychamber.org. Please type "Acknowledge" in the box below to indicate you have submitted this step. *

<<LINK TO DOWNLOAD GOES HERE>>

CCIDA/CCEDC LOAN APPLICATION PROJECT START PRIOR TO LOAN CLOSING

The undersigned hereby certifies that if commitments to purchase or actual purchases of land, building, machinery, equipment, or working capital needs have occurred before final approval is received and the loan is rejected, the undersigned will be personally responsible for such debts. *

Please type Applicant's Full Legal Name, Name of Company, Title/Position, and date applied.

CCIDA/CCEDC LOAN APPLICATION SAMPLE RESOLUTION

Click the link to view a Sample Resolution: <<Link to Download Goes Here >>

CCIDA/CCEDC LOAN APPLICATION: Financial Assistance Record

Legal Name of Company *

FEIN *

Complete the following for all public and private fund sources

Please indicate: 1.) Source of Funds (Total amount from this source, % Participation, Rate, Term, & Status) 2.) Source of Funds (Total amount from this source, % Participation, Rate, Term, & Status) 3.) CCIDA/CCEDC Loan (Total amount from this source, % Participation, Rate, Term)

Evidence that financial gaps exist and reason for CCIDA/CCEDC amount

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