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15.

Please identify the firms’ ownership: (use additional sheet if more than three owners)

NAME

Ethnicity
Sex

Years of ownership

Ownership percentage

Voting percentage

16.

Identify any owner or management official of the firm who is or has been an employee of another firm that has ownership interest or a present business relationship with your firm:

17.

List the contribution of money, equipment, real estate and percentage of expertise for each owner

(please use an additional sheet of paper if necessary):

NAME

MONEY

($)

EQUIPMENT

($)

REAL ESTATE

($)

EXPERTISE
(%)

NOTE: SUBMIT DOCUMENTED PROOF OF CONTRIBUTION FIGURES LISTED UNDER MONEY, EQUIPMENT AND REAL ESTATE.

18.

Is a license required for the product or service you provide?

Yes  c

No c    

     If yes, list the name of the license and the licensed

     individual(s) in your business (submit a copy of

     license with application):

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