APPLICANT AND CONTACT INFORMATION
Legal name of Applicant:
Business Name:
Business Start Date:
Status of Business:
Title:


Alternate / Partner Contact Name:
Business Address:
Business Telephone:
Title.:
Business Email:
Business Website:


Amount Requested from Starter Company Plus: $
Grant money to be used for :
Briefly describe the nature of the Applicant’s organization or business including its sector (arts & culture, research, education, etc.)
Provide an overview of the business.
PROJECT FINANCING

Applicant

Personal Contribution (25% min)

Source #2 (if applicable)

Source #3 (if applicable)

Starter Company Plus

Funding Type*

Funding Type1:
Funding Type2:
Funding Type3:

Funding Status**

Funding Status1:
Funding Status2:
Funding Status3:

Activities Funded

Activities Funded 1
Activities Funded 2
Activities Funded 3
Activities Funded 4

Total Funding ($)

Total Funding 1
Total Funding 2
Total Funding 3
Total Funding 4
Total
CERTIFICATION
By agreeing below, as the Applicant or an authorized signing officer of the Applicant, I certify to the Regional Business Centre that the information contained in this Application Form, which includes the supporting documentation submitted herewith, is true and complete in all respects. If the Regional Business Centre discovers that the Application Form contains any material misrepresentation, this Application Form shall be deemed to be withdrawn immediately by the Applicant. I agree to provide any additional information that the Regional Business Centre or its authorized program administrator may reasonably require for the purposes of assessing this Application Form and administering its Starter Company Plus Fund. I am aware that I am required to participate in monthly mentoring meetings for a minimum of six months upon approval of funding. I am also required to report back to the Regional Business Centre detailing revenues, cash-flow, hiring and other business details as requested. *
Name:*