Company Eligibility Questionnaire

KIZ programs exist to provide tax credit support to qualified entrepreneurs and start-up companies located in KIZ designated zones. This application is for initial assessment for WLKIZ program eligibility. Please complete this questionnaire in its entirety, sign, and returnto the Williamsport/Lycoming KIZ.

Contact Info / Business Info
PRIMARY CONTACT NAME / BUSINESS NAME
TITLE / ADDRESS STREET
PRIMARY COMPANY PHONE / CITY STATE ZIP
PRIMARY COMPANY EMAIL / EIN # (Attach Federal Business EIN Verification Letter)
COLLEGE/UNIVERSITY ATTENDED / DATE RECORDED EIN (Date Business Was Incorporated)
DEGREE/GRADUATION YEAR / OWNERSHIP TYPE (LLC, Partnership, etc.)
SECONDARY/ALTERNATE CONTACT NAME / WOMAN OWNED? / MINORITY OWNED? / VETERAN OWNED?
Y N / Y N / Y N
SECONDARY/ALTERNATE PHONE / COMPANY WEBSITE
SECONDARY/ALTERNATE EMAIL / NUMBER OF EMPLOYEES
1. / In which of the WLKIZ designated Zones are you located? (Check which one applies)
Center for Business & Workforce Development / Reach Road
Central Business District + Main Street District / Trimtex Complex, Park Avenue
Liberty Mutual Building, Sycamore Road / The Pajama Factory
2. / Date when you located, or when do you intend to locate, at this Business Address?
Note thatyou must provide a copy of: - Incorporation papers for the business, and
-Your lease confirming operation in the Zone.
3. / Please describe the nature of your business – a brief description/overview of your product/service.
4. / In which industry sector(s) of the Williamsport/Lycoming KIZ do you operate? (Check all that apply)
Advanced Manufacturing/Diversified Manufacturing
Business Services
Life Sciences
Information Technology
5. / What SIC/NAICS code you would categorize your business to be in?
(
NAICS Code
NAICS Description
6. / What is your DUNS number?
(Available through Dun & Bradstreet – - free if you apply and then wait for 30 days)
7. / Please describe the part of your business that makes it meaningfully unique, could be considered “intellectual property”, and protected via patents, trademarks, copyrights or trade secrets?
8. / In what ways might your business might be attractive to college grads and others seeking employment?
9. / What is your employment goal for this business?

By signing this document, I approve this information and agree to meet all requirements of the KIZ program. This currently includes, but is not limited to, semi-annual KIZ state reporting requirements, project updatesand IMC reporting requirements, and acquisition of a DUNS number and NAICS code. By not meeting requirements I understand that I may lose my KIZ qualification and access to programs such as, but not limited to, the KIZ Tax Credit Program.

Company Representative Signature

Name / Title
Signature / Date

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