Quad Cities Regional Economic Development Authority

Quad Cities Regional Economic Development Authority Application Legal Name and Address of Applicant
Name
Address
City	State	Zip Code
State of Incorporation
Contact Person/ Title
Phone No
FaxNo.
Federal Tax ID No./Social Security No.
Number of Full time jobs to be Created
Number of Full time jobs to be Retained

Sources and Uses of Funds
Project Costs		Sources of Funds
Land Acquisition		Bond Amount
Building Acquisition		Bank Financing
Rehabilitation		Other
New Construction		Other
New Mach. & Equipment		Other
Used Mach. & Equipment		Other
Architectural & Engineering		Other
Legal & Professional		Other
Other		Other
Other		Equity
Total Project Costs		Total Source of Funds
Certification by Applicant: Applicants are hereby notified that the provisions of the Prevailing Wage Act (IL Rev. Stats. 1979, Ch. 48, 39s-1 et seq.) and the Preference to Citizens on Public Works Project Act (IL Rev. Stats. 1979, Ch. 48, 269 et seq.) may apply to the project which is the subject of this application. Construction cost estimates should take into account the effect of these Acts. The applicant certifies by signing the application in the space below that the site for the proposed construction is not located in a Special Flood Hazard Area as defined and designated by the Illinois Department of Transportation, Division of Waterways; and that an investigation has been made to determine if it is not in such area. Applicant authorizes appropriate representatives of the Authority to undertake and complete such background investigation of the applicants company and its principal owners and officers as may be required to fully document this application. Such background investigation may include, but is not limited to, credit bureau and Dunn & Bradstreet reports, police criminal investigation reports,etc. Information developed as a result of such investigation will be held confidential and used only in regard to the review of this application. Applicant hereby certifies that all information contained in the above and in the exhibits attached hereto are true to his/her best knowledge and belief and are submitted for the purpose of obtaining financial assistance from the authority.
Signature of the Chief Executive Officer		- - Date (mm/dd/yy)