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2. APPLICATION INFORMATION
4. Company Name*
5. Company Mailing Address*
7. Owner's Name*
8. Email*
9. Phone*
11. Applicants Name (if different than owner)
12. Applicants Title
13. Applicants Email
15. Name of principal owner(s) or officers of the business
19. Does the company owe: Any delinquent taxes to the State of Ohio or a political subdivision of the State?*

    1. Yes
    2. No
21. Does the company owe: Any monies to the State or a state agency for the administration or enforcement of any environmental laws of the State?*

    1. Yes
    2. No
23. Does the company owe: Any other moneys to the State, a state agency or political subdivision of the State that are past due, whether the amounts owed are being contested in a court of law or not?*

    1. Yes
    2. No
25. If yes to any of the above, please provide details of each instance including but not limited to the location, amounts and/or case identification numbers:
29. EMPLOYMENT: As it pertains to the proposed project
31. Companies' current employment level in Ohio*
32. Companies' current employment level at the proposed project site*
34. Companies' current employment level for each facility to be affected by the relocation of employment positions or assets (if applicable)
36. Will the project involve the relocation of employment positions or assets from one Ohio location to another?*

    1. Yes
    2. No
38. State the locations from which employment positions or assets will be relocated and the location to where the employment positions or assets will be located.*
39. What is the projected impact of the relocation, detailing the number and type of employees and/or assets to be relocated.
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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

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