2. Date*
   Date

   Date
4. First Name*
5. Last Name*
7. Company
9. Street Address 1*
10. Street Address 2
12. City*
13. State*
14. Zipcode*
16. Phone
17. Email*
19. Date Business Established
20. Company's Product or Service:*
22. Does the company have a business plan?*

    1. Yes
    2. No
23. Revenue for last fiscal year:
25. Project description (including project costs and company capital available to support project):*
    (Buying an existing building, buying land and constructing a building, building renovation, purchase of machinery and equipment, etc.)
27. Financing assistance requested:*
    (Total dollar amount and what the funds will be used for.)
29. Time frame of proposed project and current status:*
30. Are you working with a bank on this project?*

    1. Yes
    2. No
32. Why is this project important to the company?
34. Current # full-time employees:*
35. Number of new full-time jobs (created as a result of the project):*
37. Who referred you to the Westmoreland Development Council (please be specific as to name and affiliation if possible)?
39. What is the best time to contact you?
    -- Select One --MorningAfternoonEvening
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41. 1. Receive an email copy of this form.
42. Email address

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43. Submit

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