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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>
<script language="javascript">
var ids=new Array();
ids[0]="busgrants";
ids[1]="edugrants";
ids[2]="comgrants";
ids[3]="pergrants";
ids[4]="reagrants";
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<style type="text/css">
<!--
.grant_category {margin-bottom:15px; width:100%}
.grant_category td {text-align:left !important}
.grant_category .txt {cursor:pointer; margin-bottom:5px}
.grant_category .txt p {display:inline; font-weight:normal; font-size:9px !important; text-transform:none; padding-left:12px}
.grant_category .txt label {font-weight:bold; text-transform:capitalize}
.grant_category .txt input {margin:3px 3px -4px 0}
.grant_category .img {background-repeat:no-repeat; background-position:top left; padding-left:55px}
.grant_category .col {width:33%}
.grant_category .hrd {font-weight:bold; text-transform:uppercase; border-bottom:1px solid #000066; height:15px}
.grant_category .hrd span {font-weight:normal; text-transform:none; font-style:italic}
.up {font-weight:bold; text-transform:uppercase !important}
-->
</style>
</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/order.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="grant_category questions">
<tr>
<td class="q up hrd">Choose which funding category you are interested in</td>
</tr>
<tr>
<td class="txt" id="bus_grant">
<label title="Business Funding">
<input type="radio" name="granttypes" id="granttype_bus" value="Business Funding" onclick="switchid('busgrants');">Business Funding
<p>Statup Capital, Expand Business, Private Money, Venture Capital, Inventions</p></label>
</td>
</tr>
<tr>
<td class="txt" id="edu_grant">
<label title="Education Funding">
<input type="radio" name="granttypes" id="granttype_edu" value="Education Funding" onclick="switchid('edugrants');">Education Funding
<p>Tuition, Student Financial Aid, Stafford Loans, Scholarships, Research</p></label>
</td>
</tr>
<tr>
<td class="txt" id="com_grant">
<label title="Community Funding">
<input type="radio" name="granttypes" id="granttype_com" value="Community Funding" onclick="switchid('comgrants');">Community Funding
<p>Performing Arts, Humanities, Crime Prevention, Disaster Relief / Prevention</p></label>
</td>
</tr>
<tr>
<td class="txt" id="per_grant">
<label title="Personal Funding">
<input type="radio" name="granttypes" id="granttype_per" value="Personal Funding" onclick="switchid('pergrants');">Personal Funding
<p>Medical Expenses, Food Stamps, Child Care, Rent Assistance, Veterans</p></label>
</td>
</tr>
<tr>
<td class="txt" id="rea_grant">
<label title="Real Estate Funding">
<input type="radio" name="granttypes" id="granttype_rea" value="Real Estate Funding" onclick="switchid('reagrants');">Real Estate Funding
<p>1st Time Home Buyers, New Construction, Rental Properties, Commercial, Repairs</p></label>
</td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category questions" id="busgrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Business" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="busgrant_0" title="Startup Capital">
<input type="checkbox" name="busgrant_0" id="busgrant_0" value="Startup Capital">Startup Capital</label>
</td>
<td class="txt col">
<label for="busgrant_1" title="Green Business">
<input type="checkbox" name="busgrant_1" id="busgrant_1" value="Green Business">Green Business</label>
</td>
<td class="txt col">
<label for="busgrant_2" title="Minority Owned">
<input type="checkbox" name="busgrant_2" id="busgrant_2" value="Minority Owned">Minority Owned</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="busgrant_3" title="Expand Business">
<input type="checkbox" name="busgrant_3" id="busgrant_3" value="Expand">Expand Business</label>
</td>
<td class="txt col">
<label for="busgrant_4" title="Training">
<input type="checkbox" name="busgrant_4" id="busgrant_4" value="Training">Training</label>
</td>
<td class="txt col">
<label for="busgrant_5" title="Invention">
<input type="checkbox" name="busgrant_5" id="busgrant_5" value="Invention">Invention</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="busgrant_6" title="Women Owned">
<input type="checkbox" name="busgrant_6" id="busgrant_6" value="Women Owned">Women Owned</label>
</td>
<td class="txt col">
<label for="busgrant_7" title="Technology">
<input type="checkbox" name="busgrant_7" id="busgrant_7" value="Technology">Technology</label>
</td>
<td class="txt col"> </td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category questions" id="edugrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Education" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="edugrant_0" title="Tuition">
<input type="checkbox" name="edugrant_0" id="edugrant_0" value="Tuition">Tuition</label>
</td>
<td class="txt col">
<label for="edugrant_1" title="Interships">
<input type="checkbox" name="edugrant_1" id="edugrant_1" value="Interships">Interships</label>
</td>
<td class="txt col">
<label for="edugrant_2" title="Training">
<input type="checkbox" name="edugrant_2" id="edugrant_2" value="Training">Training</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="edugrant_3" title="Scholarships">
<input type="checkbox" name="edugrant_3" id="edugrant_3" value="Scholarships">Scholarships</label>
</td>
<td class="txt col">
<label for="edugrant_4" title="Housing / Boarding">
<input type="checkbox" name="edugrant_4" id="edugrant_4" value="Housing / Boarding">Housing / Boarding</label>
</td>
<td class="txt col">
<label for="edugrant_5" title="Research Grants">
<input type="checkbox" name="edugrant_5" id="edugrant_5" value="Research Grants">Research Funding</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="edugrant_6" title="University Grants">
<input type="checkbox" name="edugrant_6" id="edugrant_6" value="University Grants">University Funding</label>
</td>
<td class="txt col">
<label for="edugrant_7" title="Teacher / Staff">
<input type="checkbox" name="edugrant_7" id="edugrant_7" value="Teacher / Staff">Teacher / Staff</label>
</td>
<td class="txt col">
<label for="edugrant_8" title="Science">
<input type="checkbox" name="edugrant_8" id="edugrant_8" value="Science">Science</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="edugrant_9" title="Technology">
<input type="checkbox" name="edugrant_9" id="edugrant_9" value="Technology">Technology</label>
</td>
<td class="txt col"> </td>
<td class="txt col"> </td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category questions" id="comgrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Community" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_0" title="Disaster Relief">
<input type="checkbox" name="comgrant_0" id="comgrant_0" value="Disaster Relief">Disaster Relief</label>
</td>
<td class="txt col">
<label for="comgrant_1" title="Disaster Prevention">
<input type="checkbox" name="comgrant_1" id="comgrant_1" value="Disaster Prevention">Disaster Prevention</label>
</td>
<td class="txt col">
<label for="comgrant_2" title="Crime Prevention">
<input type="checkbox" name="comgrant_2" id="comgrant_2" value="Crime Prevention">Crime Prevention</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_3" title="Performing Arts">
<input type="checkbox" name="comgrant_3" id="comgrant_3" value="Performing Arts">Performing Arts</label>
</td>
<td class="txt col">
<label for="comgrant_4" title="Historical Sites">
<input type="checkbox" name="comgrant_4" id="comgrant_4" value="Historical Sites">Historical Sites</label>
</td>
<td class="txt col">
<label for="comgrant_5" title="Humanities">
<input type="checkbox" name="comgrant_5" id="comgrant_5" value="Humanities">Humanities</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_6" title="Non Profit">
<input type="checkbox" name="comgrant_6" id="comgrant_6" value="Non Profit">Non Profit</label>
</td>
<td class="txt col">
<label for="comgrant_7" title="Arts">
<input type="checkbox" name="comgrant_7" id="comgrant_7" value="Arts">Arts</label>
</td>
<td class="txt col">
<label for="comgrant_8" title="Transportation">
<input type="checkbox" name="comgrant_8" id="comgrant_8" value="Transportation">Transportation</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_9" title="Green Community">
<input type="checkbox" name="comgrant_9" id="comgrant_9" value="Green Community">Green Community</label>
</td>
<td class="txt col">
<label for="comgrant_a" title="Senior">
<input type="checkbox" name="comgrant_a" id="comgrant_a" value="Senior">Senior</label>
</td>
<td class="txt col">
<label for="comgrant_b" title="Social Services">
<input type="checkbox" name="comgrant_b" id="comgrant_b" value="Social Services">Social Services</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="comgrant_c" title="Environmental">
<input type="checkbox" name="comgrant_c" id="comgrant_c" value="Environmental">Environmental</label>
</td>
<td class="txt col"> </td>
<td class="txt col"> </td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category questions" id="pergrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Personal" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="pergrant_0" title="Bills">
<input type="checkbox" name="pergrant_0" id="pergrant_0" value="Bills">Bills</label>
</td>
<td class="txt col">
<label for="pergrant_1" title="Medical Expenses">
<input type="checkbox" name="pergrant_1" id="pergrant_1" value="Medical Expenses">Medical Expenses</label>
</td>
<td class="txt col">
<label for="pergrant_2" title="Child Care">
<input type="checkbox" name="pergrant_2" id="pergrant_2" value="Child Care">Child Care</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="pergrant_3" title="Utility Bills">
<input type="checkbox" name="pergrant_3" id="pergrant_3" value="Utility Bills">Utility Bills</label>
</td>
<td class="txt col">
<label for="pergrant_4" title="Rent Assistance">
<input type="checkbox" name="pergrant_4" id="pergrant_4" value="Rent Assistance">Rent Assistance</label>
</td>
<td class="txt col">
<label for="pergrant_5" title="Food Stamps">
<input type="checkbox" name="pergrant_5" id="pergrant_5" value="Food Stamps">Food Stamps</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="pergrant_6" title="Drug Abuse Treatment">
<input type="checkbox" name="pergrant_6" id="pergrant_6" value="Drug Abuse Treatment">Drug Abuse Treatment</label>
</td>
<td class="txt col">
<label for="pergrant_7" title="Veterans">
<input type="checkbox" name="pergrant_7" id="pergrant_7" value="Veterans">Veterans</label>
</td>
<td class="txt col">
<label for="pergrant_8" title="Low Income">
<input type="checkbox" name="pergrant_8" id="pergrant_8" value="Low Income">Low Income</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="pergrant_9" title="Senior">
<input type="checkbox" name="pergrant_9" id="pergrant_9" value="Senior">Senior</label>
</td>
<td class="txt col">
<label for="pergrant_a" title="Food / Nutrition">
<input type="checkbox" name="pergrant_a" id="pergrant_a" value="Food / Nutrition">Food / Nutrition</label>
</td>
<td class="txt col"> </td>
</tr>
</table>
<table cellpadding="2" cellspacing="0" class="grant_category questions" id="reagrants" style="display:none">
<tr>
<td colspan="3" class="hrd">Suggested "Real Estate" Sub-Categories <span>(Check all that apply)</span></td>
</tr>
<tr>
<td class="txt col">
<label for="reagrant0" title="Rental Properties">
<input type="checkbox" name="reagrant0" id="reagrant0" value="Rental Properties">Rental Properties</label>
</td>
<td class="txt col">
<label for="reagrant1" title="1st Time Home Buyers">
<input type="checkbox" name="reagrant1" id="reagrant1" value="1st Time Home Buyers">1st Time Home Buyers</label>
</td>
<td class="txt col">
<label for="reagrant2" title="Apartment Buildings">
<input type="checkbox" name="reagrant2" id="reagrant2" value="Apartment Buildings">Apartment Buildings</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="reagrant3" title="RV Parks">
<input type="checkbox" name="reagrant3" id="reagrant3" value="RV Parks">RV Parks</label>
</td>
<td class="txt col">
<label for="reagrant4" title="Mobile Home Parks">
<input type="checkbox" name="reagrant4" id="reagrant4" value="Mobile Home Parks">Mobile Home Parks</label>
</td>
<td class="txt col">
<label for="reagrant5" title="Commerical">
<input type="checkbox" name="reagrant5" id="reagrant5" value="Commerical">Commerical</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="reagrant6" title="Land Development">
<input type="checkbox" name="reagrant6" id="reagrant6" value="Land Development">Land Development</label>
</td>
<td class="txt col">
<label for="reagrant7" title="New Construction">
<input type="checkbox" name="reagrant7" id="reagrant7" value="New Construction">New Construction</label>
</td>
<td class="txt col">
<label for="reagrant8" title="Property Repair">
<input type="checkbox" name="reagrant8" id="reagrant8" value="Property Repair">Property Repair</label>
</td>
</tr>
<tr>
<td class="txt col">
<label for="reagrant9" title="Historic Renovation">
<input type="checkbox" name="reagrant9" id="reagrant9" value="Historic Renovation">Historic Renovation</label>
</td>
<td class="txt col">
<label for="reagranta" title="Home Improvements">
<input type="checkbox" name="reagranta" id="reagranta" value="Home Improvements">Home Improvements</label>
</td>
<td class="txt col"> </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 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"); ?>