Form Fiia-01 - Eligibility Application
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4West V ir ginia
Film Indust r y Invest ment Act
Form FIIA-01: Eligibility Application
Par t I – GENER AL INFORMATION
Applicant Company Name ______________________________________________________ FEIN/SSN ___________________________________________
Physical Street Address ______________________________________________________________________________________________________________
Select country...
Select state...
City _________________________________________ State _________________________ Zip _________________ Country ________________________
Phone ______________________________________ Fax ____________________________________ Email ______________________________________
Primary Contact _______________________________________________________________ Title _______________________________________________
(Person with whom WVFO is authorized to discuss pending application.)
l Check box if contact information of Primary Contact is same as Applicant Company. If not, complete information below.
Address ____________________________________________________________________________________________________________________________
Select state...
Select country...
City _________________________________________ State _________________________ Zip _________________ Country ________________________
Phone ______________________________________ Fax ____________________________________ Email ______________________________________
Secondary Contact (if any) Authorized to Discuss Pending Application:
Name ________________________________________________________________________ Title _______________________________________________
Phone ______________________________________ Fax ____________________________________ Email ______________________________________
Par t II – PRODUCTION INFORMATION
Type of Production:
l Feature Length Theatrical
l Feature Length Direct-to-Video
l Commercial
l Commercial Still Photography
l Music Video
l Television MOW
l Television Mini-Series
l Television Series
l Television Pilot
l Other (explain) ______________________________________________________________________________________
Production Title:_____________________________________________________________________________________________________________
Production Description (synopsis):
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Department Use Only
Date/Time Rec. _____________________________
Received By ________________________________
Application # _______________________________
West Virginia Film Office 90 MacCorkle Avenue, SW • South Charleston, WV 25303 • 866-698-3456 •
Form FIIA-01
9/14/12
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Parent category: Business