INNOVATION LOAN FUND APPLICATION (LIFT)
BANK OF NORTH DAKOTA
General
General
Company Name
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Social Security # (SSN)/Federal Tax Id #
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Primary Contact First Name
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Primary Contact Last Name
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Primary Contact Title
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Address
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City
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State
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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
Zip Code
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Telephone Number
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Email Address
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Section
Legal Structure
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Corporation
General Partnership
Limited Liability Company
Limited Partnership
Non-Profit
Sole Proprietorship
Sub Chapter S Corporation
Date Business Established
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Provide a Brief Description of the Intellectual Property being Commercialized and how the LIFT Funds will be Used
Project Description
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Current Number of Employees
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Projected Number of Employes (within 24 months)
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Current Average Wage Plus Benefits
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Projected Average Wage Plus Benefits (w/i 24 mo)
*
MARIJUANA RELATED BUSINESS ACTIVITIES
Will loan proceeds be used for any marijuana related business activities?
Will loan proceeds be used for any marijuana related business activities?
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Yes
No
Does the borrower or co-borrower generate revenue from marijuana related business activities?
Does the borrower or co-borrower generate revenue from marijuana related business activities?
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Yes
No
If yes, what percentage?
Borrower/Co-Borrower will notify BND immediately if they become involved in any marijuana related business activities.
Borrower/Co-Borrower will notify BND immediately if they become involved in any marijuana related bu
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Yes
No
I/We certify that the Marijuana Related Business Activities questions above are true and correct as of the date of this application.
Please initial here:
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Section
Section
Primary Contact First Name
*
Primary Contact Last Name
*
Signature
*
Signature Date
*