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Directors & Officers Application
1
Organization Information
2
Employee Information
3
Financial Information
Business Name
(Required)
Entities
Please provide a schedule of all entities in which the Applicant’s ownership is 50% or greater or which the applicant has management control. Include the entity name, % owned, year started, description of operations, and entity type.
Entities
Entity Name
% Owned
Year Started
Description of Operations
Entity Type
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Entity Type: FP=For-Profit; GP=General Partnership; LP=Limited Partnership; LLC=Limited Liability Company
Total number of employees (full and part time including leased, seasonal, and temporary employees)
Full Time Employees
Part Time Employees
Volunteers
Independent Contractors
Most Recent Fiscal Year
Current Assets
Total Assets
Current Liabilities
Retained Earnings (Accumulated Deficit)
Net Equity/Net Assets (Deficit Equity)
Revenues
Net Income (Net Loss)
Stock Ownership/ total number of voting shareholders:
How many Directors / Officers does the organization have?
1
2
3
4
5
6+
Director / Officer
Director / Officer
Name
% of Voting Shares Owned:
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