Company Name :

Primary Contact & Title at Company :

Company Address :

Phone :

Fax :

E-mail :

Website :

The company has been in business since :

If applicable, please provide the name and state (or country) of your parent company :

Major markets & customers :

Business product(s) and/or services :

Are your products/services sold: Wholesale?YesNo

Retail?YesNo

Is this a manufacturing operation?YesNo

Does the company participate in international trade?YesNo

If so, how?

What size facility is your company interested in?

Does your company need high clear-span ceilings?YesNo

High door heights?YesNo

Loading docks?YesNo

Does your company have high water/sewer needs? If so please describe :

Does your company have any special electrical needs such as three phase? If so please describe :

Does your company have any special broadband needs? If so please describe :

Does your company have future expansion plans?YesNo

If so, please describe your space needs and timeframe of expansion(s)?

Please describe any other special facility needs your company may have?

What is the anticipated dollar investment and timeframe related to the company’s immediate plans?

Building :

Estimated move-in date :

M&E: :

Estimated date to be placed in service :

Does the company need or want financial assistance?YesNo

If yes, how much financing is desired and what will the funds be used for? Please provide as much detail as possible & feel free to use additional space.

Do you have clearly delineated product research and development activities?YesNo

Does your company have any specific employment training needs? If so, please attach a description of the types of training you anticipate needing for both new and existing employees, including the anticipated cost for the training, if possible. If a proposed training plan has been developed, please attach a copy. :

Does the company offer health insurance to employees?YesNo

If so, does the company pay 50% or more of the premium cost for this insurance?YesNo

Does the company provide an ERISA-qualified retirement plan to employees?YesNo

What is your current number of employees?

Full-time :

Part-time :

Will your company be adding new positions over the next two (2) years?YesNo

If so, please indicate the number of positions to be created for each of the next two years. Also, please provide anticipated job titles and wages for all net new, full-time jobs. Attach additional sheets as necessary.

Year 1 :

Full-time :

Part-time :

Full-time job title(s), with anticipated wages :

Year 2 :

Full-time :

Part-time :

Full-time job title(s), with anticipated wages :

To help determine if the Department of Environmental Protection needs to assist your company, please review the following:

Will any hazardous wastes be generated, stored or treated at this location?YesNo

Does your process involve the use of coatings or solvents (e.g. printing, painting, refinishing, cleaning)?YesNo