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* 1. First + Last Name:

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* 2. Email Address:

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* 3. Phone Number:

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* 4. Street Address:

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* 5. City:

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* 6. Postal Code:

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* 7. Business Name:

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* 8. Is your business in operation?

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* 9. If yes, business start date:

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* 10. Business Address (if different than above):

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* 11. Business Website:

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* 12. Business Social Media Accounts:

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* 13. Provide a brief overview of the business:

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* 14. Provide a brief description of how your product or service is different from those in your industry

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* 15. Application Type:

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* 16. Amount Requested from Starter Company Plus:
(max $5,000)

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* 17. Grant money to be used for:

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* 18. How did you hear about Starter Company Plus?

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* 19. Please check all that apply to confirm your eligibility in the Starter Company Plus Program:

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* 20. Please check all that apply to confirm you understand some of the Starter Company Plus requirements.  Additional information can be found at: www.regionalbusiness.ca/startercompanyplus

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* 21. By agreeing below, as the Applicant or an authorized signing officer of the Applicant, I certify to the Regional Business Centre that the information contained in this Application Form, which includes the supporting documentation submitted herewith, is true and complete in all respects.  If the Regional Business Centre discovers that the Application Form contains any material misrepresentation, this Application Form shall be deemed to be withdrawn immediately by the Applicant.  I agree to provide any additional information that the Regional Business Centre or its authorized program administrator may reasonably require for the purposes of assessing this Application Form and administering its Starter Company Plus fund.  I am also required to report back to the Regional Business Centre detailing revenues, cash-flow, hiring and other business details as requested.

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