State Form 52341 - Qualified Indiana Business Application Page 2
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1
2OTHER COMPANY RELATED INFORMATION
The qualified Indiana Business Applicant is engaged in the following (
):
Real estate
Real estate development
Application of new technology
Commercialization of research and development
Accounting
Technology transfer
Professional motor vehicle racing
Retail sales
Insurance
Oil or gas exploration
Professional services as a lawyer or physician
Amount of revenue generated last year
Amount of revenue generated the year before last
Amount of capital company plans to raise in this round
Amount of capital from outside Indiana
Total value of company assets
Value of those assets in Indiana
EMPLOYMENT INFORMATION
Now
End Year One
End Year Two
Thereafter
Total company employment
Total employment of Indiana residents
AFFIRMATION
I affirm, under the penalties for perjury, that the information contained herein is true and accurate to the best of my knowledge and belief.
I furthermore affirm that I have read and understand the statute governing this program (IC 6-3.1-24).
Signature
Date (
)
Printed name
Title
Page 2 of 2
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Parent category: Legal