INNOVATION LOAN FUND APPLICATION (LIFT)
BANK OF NORTH DAKOTA
COMPANY/APPLICANT INFORMATION
General
Company Name
*
Required
Social Security # (SSN)/Federal Tax Id #
*
Required
Primary Contact First Name
*
Required
Primary Contact Last Name
*
Required
Primary Contact Title
*
Required
Address
*
Required
City
*
Required
State
*
Select One
ND
AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Required
Zip Code
*
Required
Telephone Number
*
Required
Email Address
*
Required
Section
Legal Structure
*
Corporation
General Partnership
Limited Liability Company
Limited Partnership
Non-Profit
Sole Proprietorship
Sub Chapter S Corporation
Required
Business Status
*
New
Existing
Purchase Existing
Required
Date Business Established
*
Required
INTELLECTUAL PROPERTY AND COMMERCIALIZATION PLAN
Provide a Brief Description of the Intellectual Property being Commercialized and how the LIFT Funds will be Used
Project Description
*
Required
Current Number of Employees
*
Required
Enter a decimal value.
Projected Number of Employes (within 24 months)
*
Required
Enter a decimal value.
Current Average Wage Plus Benefits
*
Required
Enter a currency value.
Projected Average Wage Plus Benefits (w/i 24 mo)
*
Required
Enter a currency value.
Section
Section
Signature
*
Required
Signature Date
*
Required