Small Business Service Provider Grants

Application

Office of the Governor

Economic Development and Tourism

Applicant Name:

Applicant Mailing Address:

Project Title:

Date Submitted:

As of May 17, 2017

Refer to the Application section of the Funding Announcement and Guidelines document accompanying this grant programwhen completing this application form for instructions and definitions.

DO NOT LEAVE ANY FIELDS BLANK. If field does not apply, enter “N/A.”

If you have any questions regarding this application, please contact the Office of the Governor - Economic Development and Tourism at 512-936-0100.

APPLICANT INFORMATION
Name:
Applicant Type: Choose an item.
If “Other,” please list your entity type:
Division/Unit responsible for project administration:
Physical Address:
Mailing Address (if same, type “N/A”):
Primary Service Area:
Primary Functions/Activities:
Data Universal Numbering System (DUNS) Number:
System for Award Management (SAM) Registration
SAM Expiration Date:
Is your organization actively seeking a valid SAM registration? Choose an item.
Authorized Representative
Name: / Title:
Email: / Phone:
Project Director
Name: / Title:
Email: / Phone:
PROJECT DATA
Coverage Area: Please reference this county or group of countiesto answer questions 3-5.
County Name(s):
REMINDER: Please use the definitions of “rural” and “urban” given in the Funding Announcement and Guidelines document to answer questions 1 and 2.
1. Using the Physical Address given in the table above, is your organization located in a rural or urban area? / Choose an item.
2. What percentage of the project’s activities will impact small businesses in rural areas? / Choose an item.
3. How many Office of the Governor Small Business Initiatives (including Small Business Forums, Small Business Workshops, and Small Business Service Provider Grants) have been awarded to your organization since January 1, 2015?
If you answered one or more, list the applicable initiatives, including dates:
PROJECT DETAILS
Title:
Total Requested Grant Amount:
Detailed Project Description:
Target Group (include the number and geographic and demographic characteristics of the small businesses being served):
Identify the need or gap that this project seeks to fill in the Coverage Area:
Has your organization previously carried out a similar project? / Choose an item.
If “Yes,” describe the nature and frequency of any similar project(s):
Will you be working with another organization to complete this project? / Choose an item.
If “Yes,” please list all organizations you will be working with:
How many staff members will assist with the completion of this project?
Will there be any additional funding sources supporting the project (organization funds, attendance fees, etc.)? / Choose an item.
If ”Yes,” please provide detail:
Complete only ONE of the following sections.
If your project is an EVENT of any kind (includes training courses), answer the following questions:
Event Date(s): / Event Venue:
If your project is NOT AN EVENT, answer the following questions:
Anticipated Project Start Date: / Anticipated Project Completion Date:
PROJECT MILESTONES
Completion Date / Action
1
2
3
4
5
6
PROJECTED PROJECT IMPACT
Estimated Number of Unique Small Business Entities (USBEs) served
Estimated Number of Historically Underutilized Businesses (HUBs) served
Estimated Number of Unique Small Business Service Providers (USBSPs) participating
Provide the names of all participating USBSPs (if applicable):
Describe your organization’s plans for sustaining this project beyond the period of this round of SBSP grant funding. Identify potential future funding sources, staffing levels, long-term usefulness of materials developed, ongoing training for participants, etc.NOTE: Indicate any outputs created as a result of this project that will continue in existence beyond the term of the contract.
Outputs
1.
2.
3.
Outcomes / Timeframe
Short-Term
1.
2.
Long-Term
1.
2.

Application Checklist

Completed application form

Budget worksheet

Send your completed application packet, including all of the materials listed in the checklist above, to no later than11:59 PM CDT on Monday, June 12, 2017. Early submission is encouraged.

The application packet will include a pdf of the signed application and budget worksheet, as well as, a soft Word copy of the application and a soft Excel version of the Proposed Budget Worksheet.

I, the authorized representative of the applicant, certify that the representations made, the facts stated in this application and all supplemental documents are true and correct, and that no relevant facts have been intentionally omitted, as evidenced by my signature below. I hereby agree, on behalf of the applicant, to comply with the reporting requirements and will provide other documentation as requested.

Signature

Name (Printed)

Title

Date

1