TIME Program Application

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This field is required, include the applicant's full name.

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This field is required, include the applicant's address.

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This field is required, include the applicant's email address.

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This field is required, include the applicant's phone number.

Section I, Business Information:

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This field is required, include the name of the business.

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This field is required, include the address of the business.

Business Owner #1 Information:

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This field is required, include Owner #1's full name.

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This field is required, include Owner #1's ownership percentage of the business.
Round to the nearest whole number from 1 to 100.

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Business Owner #2 Information:

Additional Business Owners:

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This field is required, include the date the business was established.

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This field is required, include the tax identification number of the business.

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Forms of Operation:

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• Violates any U.S. federal or state law.

• Owned/controlled by any government agency, public administration, political organization, or non-profit of any type, including labor groups. 

• Are engaged in any illegal activity (other than routine traffic violations);

• Are primarily in the business of manufacturing, promoting or selling diet aids, cannabis, gambling, tobacco (including tobacco-related equipment, such as e-cigarettes), firearms or other weapons. 

• Are private clubs and businesses which limit the number of memberships for reasons other than capacity or related to applicable U.S. federal or state health guidelines; 

• Are principally engaged in teaching, instructing, counseling or indoctrinating religion or religious beliefs, whether in a religious or secular setting. 

• Derive directly or indirectly more than de minimis gross revenue through the sale of products or services, or the presentation of any depictions or displays, of a sexual nature. 

• Are fraternities, sororities or alumni groups;

• Are owned by employees, officers and directors of the Columbus Area Chamber of Commerce Foundation, Inc or the NAACP Columbus/Bartholomew Branch 3071 and any affiliated entities, and their respective immediate families (parents, spouse, children, siblings) or individuals residing in their household (whether or not related); 

• Are listed on the U.S. Department of the Treasury’s Sanctions List.

Section II, Financing Information and Use of Funds:

Funds from this program may only be used for specific expenditures and in certain situations. Please review allowable uses below:

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Allowable expenses from Funding

• Rent, Operating capital for leasing space

• Cost of Goods Sold (food cost, materials)

• Marketing materials and advertising including website development and servicing

• Licenses, dues, subscriptions

• Phone and Internet

• Supplies

• Insurance and/or utilities

• Staff salaries

• Equipment Leases and Software Payments, Equipment purchase (with or without installation costs)

• Purchasing inventory, supplies, accounting and inventory software, furniture, fixtures, and equipment

• Professional services including legal, financial, business consulting services, 

• Costs of design and retrofitting businesses to accommodate social distancing, including developing Covid-19 related policies

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Ineligible use of Funding

• Pay off non-business debt, such as personal credit cards for purchases not associated with the business

• Purchase personal expenses such as buying a new family car or making repairs to a participant's home

• Purchase personal items, or support other businesses in which the borrower may have an interest

• Distribute funds to a director or entity owned/controlled by a director

• Programs designed to influence - or fund through political contributions - a particular law, election or politically-oriented cause, including voter registration and organized labor organizations and programs;

• Any program that results in direct financial benefit to a specific individual, or an individual sponsorship related to fundraising activities;

• Religious programs or sectarian programs for religious purposes;

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This field is required, include the amount of funding being requested.

Round to the nearest whole number. A dollar sign is not required.

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This field is required, include a description of how you plan to use the funding.

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If yes, what is/are your potential source(s) of repayment:

Section III, Legal and Other Topics:

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Section IV, Other Supporting Information:

Section V, Certifications:

Please read the following and sign the Application Form below.

• The information in this application is provided for the purpose of applying for funds under the TIME Program.

• The information is accurate to the best of my knowledge and I understand if I falsify any information it may make me ineligible for future support extended by programs of NAACP Columbus/Bartholomew Branch 3071.

• I understand that personal and/or business financial and credit information may be requested pursuant to this funding application, and I hereby give my consent for such information to be provided to the NAACP Columbus/Bartholomew Branch 3071, First Financial Bank, and/or Columbus Area Chamber of Commerce, or Columbus Area Chamber of Commerce Foundation representatives.

• I understand that the TIME program retains the sole discretion as to whether this funding application is approved, disapproved, or modified.

• I understand that it is my right to accept or decline the funding amount, rate and terms approved through the program.

• I have included a complete, signed W9 form with this application.

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This field is required, include the printed name of the applicant who signs below.

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This field is required, include the digital signature of the applicant.

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This field is required, include the date this application was signed.

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