Retention and Modernization Program Pre-Certification Application Form

General Information

Company name:
Company address:
Company city:
Company state:		Company ZIP code:
Company parish/county:
SIC code:	or NAICS code:
Federal Employer ID No. (FEIN or EIN):
LA Dept of Revenue ID No. (on form LDOL-ES4 Employer’s Wage and Tax Report):
LA Workforce Commission Unemployment Insurance ID No.:
Company contact:
Contact email address:
Contact phone number:
Facility same as above
Facility address:
Facility city:
Facility state:		Facility ZIP code:
Facility parish:
Project description (reason for request):
Competing location(s) for capital investment (city, state, country):
Capital expenditure amount $$$:
Tax credit amount requested $$$:
Parent company name:
Parent company address:
Parent company city:
Outside USA?
Parent company state:
Parent company ZIP code:
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):

Construction Information

Year construction begins:
Construction start date:
Construction end date:
Construction period (__year(s)/__month(s):
Construction employment (FTE):
Total annual construction payroll:
Construction materials:
Equipment purchases:
Date operation begins (month/day/year):

Job Creation/Payroll (Excluding Benefits)

	Year 1	Year 2	Year 3	Year 4	Year 5	Year 6	Year 7	Year 8	Year 9	Year 10
Data Entry Instructions: Enter Numeric values in whole numbers only; no alpha or special characters (includes dollar sign, comma, period). Do not copy and paste repetitive data. To change an entry, highlight the data, select delete, enter new data and tab to the next field.
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 Budget

Project Cost Categories	Local Government	Federal Government	Other Assistance	Private	Total Cost
Data Entry Instructions: Enter Numeric values in whole numbers only; no alpha or special characters (includes dollar sign, comma, period). Do not copy and paste repetitive data. To change an entry, highlight the data, select delete, enter new data and tab to the next field.
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):

In applying for this incentive program, my company understands and accepts that an incentive award would require a public disclosure by LED of our projected job retention (and, if applicable, creation) totals, total retained and new payroll, and total capital investment, as well as a brief summary of the project and how it will impact our company's competitiveness.