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Return to Earn - Application
To request funding, please complete the application below.
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Business Name *
Legal Business Name (If different from above) *
Federal Employer Identification Number (FEIN#) *
Business Location *
Business Industry *
Employer Contact Name *
Employer Telephone *
Email *
Number of Current Employees *
Number of New Hires that Reimbursement is being Requested *
Date of New Hires *
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Have New Hires attested to being unemployed for 30 or more days prior to hire date? *
Hourly Wages of New Hires *
Amount of Return to Earn Funding Requested per New Hire *
I attest that my company is incorporated in Virginia, and not currently disbarred from receiving federal or state funds and is current on all state obligations. I attest that the funding will not be used to offset my company’s share of the West Piedmont Region's Return to Earn hiring incentive. *
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