2. This is a pre-screen questionnaire to gauge eligibility for the program, and does not guarantee funding.  It is the first step in determining applicants' eligibility to receive funding.

   Please be aware that this grant is reimbursable!

   After the prescreen questionnaire has been submitted we will be in touch to discuss next steps.  Any additional questions or concerns about this questionnaire contact Rachel Paul, Planning & Outreach Coordinator, at 301-739-8577 ext. 820 and by email at rpaul@hagerstownmd.org

   (Please note all answers to the below questions will be kept confidential.)

4. Business Name*
6. Business Address*

   Please note only business located in the City of Hagerstown or who do two-thirds of their business in the City of Hagerstown are eligible for funding.

8. Owner's Name*
10. Owner's Email Address*
12. Owner's Phone Number*
14. Month/Year Business Established *
16. Description of Business*
18. Applicants are asked to answer the following questions to determine if the applying business meets the eligibility criteria for the grant program.
20. Does your business have five or fewer employees? (This number must include the owner(s) and is reflective of total headcount)*

    1. Yes
    2. No
22. Municipal Boundary Map
    Municipal Boundary Map
24. The applying business must be located in the corporate boundaries of the City of Hagerstown. Please select yes if your business is located in the City of Hagerstown.*

    1. Yes
    2. No
28. 
30. The applying business' owner(s) must have a household income at or below the above income levels. Please select yes if the business owner's household income is at or below these levels. *

    1. Yes
    2. No
32. Grant awards are only provided to businesses that are in good standing with the City and State of Maryland, in compliance with all applicable City of Hagerstown regulations including the City's Land Management code. Please select yes if your business is in compliance. *

    1. Yes
    2. No
34. If your business has been operating for less than twelve (12) months will you be able to provide a copy of a business plan with your application?*

    1. Yes
    2. No
36. How did you hear about this program?
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field