RequestTracker Forms • Piqua, OH • CivicEngage

Business Information

Name:

Address:

City:

State:

Zip Code:

Type:

	Corporation
	Partnership

	Individually Owned
	Other

If other, please describe:

Primary Contact Information

First Name:

Last Name:

Phone Number:

Email:*

Questions

Have you received more than four (4) total citation or violations for City of Piqua Health, Building or Zoning Codes within the last two (2) years?

Yes

No

Do the individuals and entities, or the business partner or business associate of an individual or entity, or any company, firm or organization in which the individual or entity holds interest, have local, state, or federal taxes that are delinquent?

Yes

No

Are individuals and entities, or the business partner or business associate of an individual or entity, or any company, firm, or organization in which the individual or entity holds interest, delinquent on City of Piqua Income Tax?

Yes

No

Prospective Purchaser Supporting Documentation

The Prospective Purchaser must also submit the following to be considered for qualification:

• Financial Statements- documents providing evidence of the financial capability or capacity to complete revitalization projects.

• Project Portfolio- relevant experience with similar projects. Please include photos or other visuals.

• Development Team Qualifications- include any resumes of key personnel associated with the entity.

• Letters of Reference- submit at least two (2) separate professional references from persons who are familiar with the work of the entity.

Financial Statements*