* 1. Business name and address:*

* 2. Company headquarters location if different from above:*

* 3. Name of company President or Owner: *

* 4. Primary contact -  name, title, phone/email: *

* 5. What is the estimated number of full-time and part-time employees at your location?

* 6. Are you anticipating an increase or decrease in employment over the next 2 years? 

* 7. What is the  increase or decrease attributable to (i.e. entering new markets, expanding share in existing markets, renovation/expansion, new technology, addition of new product or service, other-specify, OR  declining sales, labor saving technology, improved efficiency, selling the business, retirement, other-specify).

* 8. Please describe your immediate business needs or concerns that could be addressed by local government or local private entities (i.e. transportation related; safety/emergency/medical related; building/construction related; utility related; other-specify.