Retention and Modernization Program Pre-Certification Application Form

General Information

Company name:
Company address:
Company city:
Company state:		Company zip:
Company parish:
SIC code:	or NAICS code:
Company contact:
Contact email address:
Contact phone number:
Facility same as above
Facility address:
Facility city:
Facility state:		Facility zip:
Facility parish:
Project description (reason for request):
Competing location(s) for capital investment (city, state, country):
Capital investment $$$:
Tax credit amount requested $$$:
Parent company name:
Parent company address:
Parent company city:
Outside USA?
Parent company state:
Parent company zip:
Parent company parish:
Number of current jobs (non-contract):
Number of new jobs (non-contract):
Number of retained jobs after modernization (non-contract):
Additional job description information (optional):

Year construction begins:
Construction period:
Construction employment (FTE):
Total annual construction payroll:
Construction materials:
Equipment purchases:
Date operation begins (valid for projects operational after July 1, 2011):

	Year 1	Year 2	Year 3	Year 4	Year 5	Year 6	Year 7	Year 8	Year 9	Year 10
Job Creation (net new full-time jobs)
New Job Annual Payroll
Current Jobs Retained
Retention Payroll

Value of first year Louisiana taxable operational purchases (examples: copy paper, shop towels, welding rods, maintenance supplies, non-raw materials):
Value of current annual taxable operational purchases:

Project Cost Categories	Local Government	Federal Government	Other Assistance	Private	Total Cost
Project Funds - Dollar Amount & Source (numeric values only)
Land Acquisition
Building Acquisition
Building Construction
Building Rehab./Renovation
Capital Equipment
Infrastructure Improvement
Private Fixed Assets
Other
Subtotal
Project Costs

Supporting documentation (upload files):