Leveraged Project Request Assistance

2010 Leveraged Project Assistance Request Form

Date*

My company is located in New Mexico: YesNo

My company is a small business (per U.S. Small Business Administration guidelines). YesNo

My business pays gross receipts taxes to the State of New Mexico YesNo

My company is U.S. owned and operated (not foreign owned or controlled) YesNo

Company Information
Company Name*
Contact Name - First:*		Last:*
Title:
Address:
City		County
State		Zip+4

Phone:*		Fax
Email

Leveraged Project Proposal Title:*








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