GYE2

Personal Information

First Name

Last Name

Street Address

City

State

Zip Code

Landline Telephone

Mobile Telephone

Alternate Telephone

Email Address

Date of Birth

Age

Citizenship Status

US Citizen US E-2 Visa

US Military Service

Yes No

If you answered “yes” above, please answer the next 3 questions. If you answered "no," please skip to the next section.

US Military Status

Active Duty National Guard/Reserve Discharged Honorably Discharged Other Than Honorably Retired

Branch (Check all that apply)

Do you have a service-connected disability?

Yes No

Education and Employment Information

HIGHEST level of education

Student/Employment Status (Check all that apply)

Full-time Student Part-time Student Unemployed Employed Full-time (40hr/week+) Employed Part-time

Business Information

Business Name

Business Address

City

State

Zip Code

Landline Telephone

Mobile Telephone

Give a short description of your business (A more detailed description should be included in your plan/proposal):

Is this business currently in operation?

Yes No

If no, proposed start date

Business Structure

Please note that copies of partnership agreements or articles of incorporation may be requested by Argent Technologies, LLC.

Total Grant Amount Requested

Grant Money is Intended for (Check all that apply)

General Start-up Costs General Operating Costs Specific One-time Purchase

If specific one-time purchase, give a short description of intended purchase:

For the above 2 questions, a more detailed analasis of proposed spending should be included in your plan/proposal.

Additional Documents

Please upload the following documents to your grant application:

(We prefer documents to be in the PDF format, but will also accept .doc, .docx, .jpg, .jpeg, .png, and .gif files)

W-9

Indentification

Business Plan/Grant Proposal

Application Submission

The information submitted with this form is true and accurate to the best of my knowledge.
My Name and Date below constitute the authentication of this form.

Applicant’s Name

Date Submitted