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2. DEADLINE TO SUBMIT:
   November 13, 2020 by 5:00pm
4. Please provide the following information:
6. Registered Business Name*
7. Doing Business As (Other names of business.)
9. Business License Number*
   (UBI with Washougal Endorsement Number)
10. Primary Contact Name*
12. Primary Contact Phone Number*
14. Business Address*
    (Must be within city limits.)
16. City*
17. State*
18. Zip Code*
20. Mailing Address
    (If different.)
22. City
23. State
24. Zip Code
26. Telephone Number*
27. Email Address*
29. Business Description*
31. How long has this business been in operation in Washougal?*
32. How many full-time equivalent employees does this business have?*
34. Is this business current on all federal and state business licensing requirements?*

    1. Yes
    2. No
36. Is this business a private, for profit business?*

    1. Yes
    2. No
38. Is this business an independent contracting business?*

    1. Yes
    2. No
40. Is this business a franchise or national or regional chain with locations outside of Clark County?*

    1. Yes
    2. No
42. Is this business or any of its owners currently suspended, debarred, proposed for debarment, declared ineligible, or voluntarily excluded from participation in any federal transactions?*

    1. Yes
    2. No
44. Grant Amount Requested? ($3,000 limit)*
46. What eligible uses will the funds be used for? *
48. Did this business receive a paycheck protection loan or economic injury disaster loan?*

    1. Yes
    2. No
50. Upload Supporting Documentation Below
    This includes invoices, sales receipts, proof of payment, books, documents, data or other evidence. If you require more than 4 upload fields, please send files directly to mitch.kneipp@cityofwashougal.us.
52. Supporting Documentation
53. Supporting Documentation
55. Supporting Documentation
56. Supporting Documentation
58. Certification*
    By entering my name, title and business name above, I have approved the submission of this application and certify that the information is true and correct. If I/we receive a grant, I/we agree to enter into an agreement with the City of Washougal and promise to use the grant funds in the intended manner consistent with the City’s eligibility requirements and to provide all documentation necessary for the City to verify use of the funds, if requested.
60. Electronic Signature*
61. Date*
    Date

    Date
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field