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<?
$granttype = $_GET['apptype'];
?>
<? include_once("{$_SERVER["DOCUMENT_ROOT"]}/header.php"); ?>
<script type="text/javascript" src="/assets/js/application_verify.js"></script>
</head>
<body>
<div id="size">
<div id="logo"></div>
<div id="text">
<div id="text_">
<div style="margin-left: 32px;margin-right:32px;">
<table cellpadding="2" cellspacing="0" border="0">
<tr>
<td>
<p class="header">USA Funding Applications Registration Form</p>
<p><i>The information you enter below is confidential and is only made available to a USA Funding
Applications Specialist. It is used to help the USA Funding Research team to find new funding opportunities
for you.</i></p>
<p class="header">Step 1 of 3: Tell us about <u>You</u> and <u>Your Funding Needs</u></p>
<form action="https://www.usafundingapplications.org/order2.php" method="POST" name="application" onSubmit="return verify(this);">
<fieldset>
<table cellpadding="2" cellspacing="0" class="questions">
<tr>
<td class="q">First Name:</td>
<td class="a"><input type="text" name="cc_fname" size="20"></td>
<td class="q">Last Name:</td>
<td class="a"><input type="text" name="cc_lname" size="20"></td>
</tr>
<tr>
<td class="q">Street Address:</td>
<td class="a"><input type="text" name="cc_addr" size="20"></td>
<td class="q">City:</td>
<td class="a"><input type="text" name="cc_city" size="20"></td>
</tr>
<tr>
<td class="q">State:</td>
<td class="a">
<select name="cc_state">
<option selected>Select</option>
<option value="AK">Alaska</option>
<option value="AL">Alabama</option>
<option value="AR">Arkansas</option>
<option value="AZ">Arizona</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DC">District of Columbia</option>
<option value="DE">Delaware</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="IA">Iowa</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="MA">Massachusetts</option>
<option value="MD">Maryland</option>
<option value="ME">Maine</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MO">Missouri</option>
<option value="MS">Mississippi</option>
<option value="MT">Montana</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="NE">Nebraska</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NV">Nevada</option>
<option value="NY">New York</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VI">Virgin Islands</option>
<option value="VA">Virginia</option>
<option value="VT">Vermont</option>
<option value="WA">Washington</option>
<option value="WI">Wisconsin</option>
<option value="WV">West Virginia</option>
<option value="WY">Wyoming</option>
</select>
</td>
<td class="q">Zip:</td>
<td class="a"><input type="text" name="cc_zip" size="10"></td>
</tr>
<tr>
<td class="q">Gender:</td>
<td class="a">
<select name="app_gender">
<option selected>Select...</option>
<option value="M">Male</option>
<option value="F">Female</option>
</select>
</td>
<td class="q">What is<br />your age?</td>
<td class="a">
<select name="app_age">
<option selected>Select...</option>
<option value="18-25">18-25</option>
<option value="26-34">26-34</option>
<option value="35-49">35-49</option>
<option value="50-65">50-65</option>
<option value="66-80">66-80</option>
<option value="80+">80 +</option>
</select>
</td>
</tr>
<tr>
<td class="q">Day Phone:</td>
<td class="a"><input type="text" id="cc_phonearea" name="cc_phonearea" size="3" maxlength="3" onKeyUp="tab_phone('cc_phonearea','cc_phoneprefix');">-<input type="text" id="cc_phoneprefix" name="cc_phoneprefix" size="3" maxlength="3" onKeyUp="tab_phone('cc_phoneprefix','cc_phoneextension');">-<input type="text" id="cc_phoneextension" name="cc_phoneextension" size="4" maxlength="4"></td>
<td colspan="2" class="q"> </td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" class="questions">
<tr>
<td class="q">Citizenship Status:
<select name="app_citizenship">
<option selected>Select...</option>
<option value="U.S. Citizen">U.S. Citizen</option>
<option value="Resident Alien">Resident Alien</option>
<option value="Green Card Holder">Green Card Holder</option>
<option value="Permanent Resident">Permanent Resident</option>
<option value="Not Sure">Not Sure</option>
</select>
</td>
</tr>
</table>
</fieldset>
<br />
<fieldset>
<table cellpadding="2" cellspacing="0" class="questions">
<tr>
<td colspan="2" class="q">Check funding areas you are interested in</td>
</tr>
<tr>
<?
$businessgrants = array('Small Business Funding','Small Business Management',
'Start-up Business Capital','Business Expansion Capital',
'Home Business Assistance','Women-Owned Business Funding',
'Small Business Loans','Minority-Owned Business Funding',
'Private Money','Venture Capital');
$realestategrants = array( '1st Time Home Buyer','Mobile Homes / Parks',
'Rental Housing Projects','Commercial Property',
'Apartment Buildings','Land Development',
'RV Parks','New Construction');
$educationgrants = array( 'Federal Pell','Scholarships',
'Student Financial Aid','Training Funding',
'Tuition Assistance','Research Funding',
'Stafford Loans','University Funding');
$personalgrants = array('Home Repair','Rent Assistance',
'Personal Debt Consolidation','Child Care',
'Food & Nutrition','Personal Funding',
'Medical Bills Assistance','Utility Bill Assistance');
switch ($granttype)
{
case "business":
$grants = $businessgrants;
break;
case "realestate":
$grants = $realestategrants;
break;
case "education":
$grants = $educationgrants;
break;
case "personal":
$grants = $personalgrants;
break;
default:
$grants = $businessgrants;
break;
}
$counter = 0;
foreach ($grants as $grant)
{
?>
<td class="a">
<label for="granttype_<? echo $counter; ?>" title="<? echo $grant; ?>">
<input type="checkbox" name="granttype_<? echo $counter; ?>" value="<? echo $grant; ?>" id="granttype_<? echo $counter; ?>"><? echo $grant; ?>
</label>
</td>
<?
$counter++;
if ($counter % 2 == 0)
{
echo "</tr><tr>";
}
}
?>
</tr>
<tr>
<td class="a">
Other: <input type="text" name="granttype_other" size="20">
</td>
</tr>
</table>
<input type="hidden" name="granttype" value="<? echo $granttype; ?>">
<table cellpadding="1" cellspacing="0" class="questions">
<tr>
<td class="q">How much money are you going to need?
<select name="app_amount_needed">
<option selected>Select...</option>
<option value="$500-$10,000">$500 - $10,000</option>
<option value="$10,000 - $25,000">$10,000 - $25,000</option>
<option value="$25,000 - $50,000">$25,000 - $50,000</option>
<option value="$50,000 - $100,000">$50,000 - $100,000</option>
<?
if ($granttype != 'business')
{
echo "<option value=\"$100,000 or More\">\$100,000 or More</option>";
}
else
{
?>
<option value="$100,000 - $250,000">$100,000 - $250,000</option>
<option value="$250,000 - $500,000">$250,000 - $500,000</option>
<option value="$500,000 - $1,000,000">$500,000 - $1,000,000</option>
<option value="$1,000,000 +">$1,000,000 +</option>
<?
}
?>
</select>
</td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="questions">
<tr>
<td class="q">Describe what you will use the money for:</td>
</tr>
<tr>
<td class="a"><textarea name="app_usedescription" cols="64" rows="6"></textarea></td>
</tr>
<tr>
<td class="q">What unique things would separate you from other applicants applying for this money?</td>
</tr>
<tr>
<td class="a"><textarea name="app_uniqueness" cols="64" rows="6"></textarea></td>
</tr>
</table>
</fieldset>
<br />
<fieldset>
<table cellpadding="2" cellspacing="0" class="questions">
<tr>
<td class="q">What Email address would you like to use for your Username for your Online Funding Application Account?</td>
</tr>
<tr>
<td class="a"><input type="text" name="cc_email" size="30"> <i>(ie. yourmail@hotmail.com)</i></td>
</tr>
<tr>
<td class="a"><i>** Your email is safe. We hate spam as much as you do!!</i></td>
</tr>
<tr>
<td class="a"><i>** Your <u>Email</u> will be <u>your username</u> for the USA Funding Applications website. Please double check it to be sure it is accurate!</i></td>
</tr>
<tr>
<td><input type='checkbox' checked="checked" name="email_notices" /> Yes, I would like to hear about new
funding opportunities and tips!
</td>
</tr>
</table>
</fieldset>
<center><input type="submit" value="" style="background:url(/assets/images/submit.jpg) top center no-repeat;width:144px;height:63px;border:0px;margin:20px auto;cursor:pointer"></center>
<input type="hidden" name="application" value="application">
<input type="hidden" name="tc" value="<?= $tc; ?>">
<?= $trackerformparams; ?>
</form>
</td>
</tr>
</table>
</div>
</div>
<? include_once("footer.php"); ?>