Company Name *
Name *
Title *
Business Street Address *
City *
State *
Zip Code *
Phone Number *
At what email address would you like to be contacted? *
Are you the CEO, business owner or decision maker for your company? *
Business Website
Please enter your Federal Employer Identification Number *
9 digit FEIN (XX-XXXXXXX)
How did you hear about the program? *
Please indicate all of the areas you are interested in *
Required
As a condition of acceptance into the Nevada Grow Program, I commit to the following: *
Required
Under the condition that all company indentifying information is removed, do we have your permission to use this data? *
Please best describe the industry of your business *
e.g. Transportation, Healthcare, Manufacturing, etc.
What benefit is your business to the market? What market deficiency does your business provide a solution for? Who is your target market? *
Is your company privately owned and operated? *
Business Legal Form *
When was your company founded? *
MM
/
DD
/
YYYY
Please describe your expectation for assistance *
Please select the markets where you sell your products or services *
Select all that apply.
Required
Please enter the current number of full-time W-2 employees *
Please enter the current number of part-time W-2 employees *
Please enter the current number of full-time 1099 employees *
Please enter the current number of part-time 1099 employees *
Please enter your end of year revenue for your most recent fiscal year. *
Terms and Conditions
Pursuant to the Nevada Grow Act, for a business to be selected for this Program they must have obtained the following milestones prior to application submission:

(a) Have its principal place of business within the State of Nevada and have had its principal place of business in this State for at least 2 years;
(b) Generate at least $50,000 but not more than $700,000 in revenue; and
(c) Have a business plan.

On behalf of the Applicant, I hereby authorize the College of Southern Nevada (CSN) to collect, review, and report any needed information about my business pursuant to the Nevada Grow Program, established by the Nevada Grow Act. I further agree to hold CSN harmless for all activities associated with this program.
I certify that all information provided in this application is accurate and truthful. *
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