Required fields are indicated with an asterisk.

Tier Type

“Tier 1 business” means a business that does not employ more than 20 full-time or full‐time equivalent employees. If the business is involved in providing construction services, the average annual gross receipts must not exceed $1.7 million for the three years immediately preceding the date of application. If the business is involved in the sale of goods or providing services other than construction services, the average annual gross receipts must not exceed $700,000 for the three years immediately preceding the date of application.

“Tier 2 business” means a business that does not employ more than 30 full-time or full‐time equivalent employees. If the business is involved in providing construction services, the average annual gross receipts must not exceed $3.5 million for the three years immediately preceding the date of application. If the business is involved in the sale of goods or providing services other than construction services, the average annual gross receipts must not exceed $1.3 million for the three years immediately preceding the date of application.

General Information

Legal Name of Business *

Doing Business As, if any

Street Address *

City *

State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Zip *

Mailing Details

Same as Street Address

Mailing Address

City

State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Zip

Contact Details

Name of Primary Point of Contact *

Title *

Email *

Phone *

Confirm Email *

Additional Details

Website (if any)

Federal Tax ID Number (if any)

Date Business Established *

Commercial General Liability Insurance Carrier

Policy Number

Coverage Limit

Most recent bonding limit (if applicable)

Capabilities

Please refer to the North American Industry Classification System (NAICS) http://www.census.gov/eos/www/naics/.

In the first and second columns, enter the NAICS code and NAICS description. In the third column under “Business Capability”, identify the products or services in which the qualifying business has expertise and control. See Example in the first row Enter your primary line of work on the first line after the Example line.

At least one NAICS Code entry is required.

Gross Receipts

Provide the past three years total annual gross receipts for the business as reported on federal tax returns, or those filed since the business has been in operation, if that is less than three years.

You must provide at least 1 year of total annual gross receipts or if the business was in operation for less than one year, the total gross receipts from the date the business was established to date of this application.

If the business has been in operation for less than one year, provide the total gross receipts from the date the business was established to date of this application: $

Employees

Number of full‐time or full‐time equivalent employees: *   
The hours worked by part -time and seasonal employees must be converted into full‐time equivalent hours by dividing by 2,080 the total hours worked for the applicant by all part‐time and seasonal employees.

Ownership

Is the business a subsidiary or parent company belonging to a group of firms that are owned or controlled by the same persons?

The answer to this question is required.

Licenses

Nevada Business ID *

Nevada Business License Expiration Date *

Nevada Contractor's License Number

Contractor's License Expiration Date

Additional Licenses

Provide information about other required current licenses for your business/industry to operate (if applicable)

The Nevada Governor’s Office of Economic Development reserves the right to request additional documentation from certified Local Emerging Small Businesses as needed in order to determine continued qualification and eligibility for the program. Following a request, documentation shall be submitted within 30 days, otherwise certification may be revoked.

It is the responsibility of the applicant to ensure that the Nevada Governor’s Office of Economic Development has a current business address, email address, and phone number. The applicant shall notify the Nevada Governor’s Office of Economic Development of any changes in the information provided in its application that may affect its continued eligibility.

Certification as a Local Emerging Small Business is valid until 2 years after the last day of the month in which it is issued or renewed, unless certification is renewed.

Written notice of determination will be provided to all applicants within 90 days of receipt of application. Information about certified ESBs will be made public in an online directory.

I DECLARE, AS A DULY AUTHORIZED REPRESENTATIVE OF THE APPLICANT LISTED HEREIN, THAT THE APPLICANT IS QUALIFIED AS EITHER A TIER 1 OR TIER 2 LOCAL EMERGING SMALL BUSINESS.

I FURTHER DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION PROVIDED IN THIS APPLICATION AND SUPPORTING DOCUMENTS IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Signature (type your full name) *

Title *

Date *