2. Date of Application*
   Date of Application
4. I have read and understand the Grant Application Guidelines.*

   1. Agree
5. I have read and completed the Eligible Item Worksheet*

   1. Agree
7. Name*
9. Contact Phone Number*
10. Contact Email Address*
12. Contact/Mailing Address*
14. City*
15. State*
16. Zip Code*
18. Legal Business Name*
20. d/b/a Name (If Applicable)
22. Property Owner Name (if different than above)
24. Property Owner Phone (if different than above)
25. Property Owner Email (if different than above)
27. How many locations does this business have?*
28. Of the total how many are located in West Fargo?*
30. Is the business licensed in the State of North Dakota?*

    1. Yes
    2. No
31. Will grant funds be used for an EXISITING or NEW operation?*

    1. Existing
    2. New
32. Is the business operating an in-home child care or a child care center?*

    1. In-Home Care
    2. Child Care Center
33. Does this business OWN or LEASE the space they are currently operating?*

    1. Own
    2. Lease
35. Provide proof of current ND Child Care License
39. Is business current on payment of West Fargo taxes and special assessments?*

    1. Yes
    2. No
40. Is business located in the City of West Fargo?*

    1. Yes
    2. No
41. Is business owned by a U.S. citizen or permanent U.S. resident?*

    1. Yes
    2. No
43. Any improvements completed with grant funds must comply with City of West Fargo zoning and building codes.*

    1. I agree
47. Request Amount (Up to $50,000)*

    Provider Type	Potential Capacity	Maximum Award Amount
    In-Home Child Care	7 Children	$7,500
    Group Home Child Care	20+ Children	$10,000
    School Age Center	20 + Children	$20,000
    Early Learning Centers	20+ Children	$50,000

49. Request for Infant Room Fit-Up (Up to $15,000)

    Child care centers only

51. Request Summary*

    Provide a brief narrative of how this grant will impact your business, and how your use of funds will meet the grant program goals.
    
    You may upload this summary as a Word Document or PDF in the space below. If so, please enter "Document Provided" in the Request Summary space.

53. Upload Completed Eligible Item Worksheet*
55. Upload Supporting Documents*

    May include:
    -Contractors Estimate
    -Budget Plans
    -Renderings
    -Itemized Contract for Service
    -Business Plans

    Each project is different. Please contact West Fargo Economic Development to determine which documents you may need.

57. Additional Supporting Document
58. Additional Supporting Document
59. Additional Supporting Document
60. Additional Supporting Document
64. How did you hear about this program?
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field