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