Join the PCKIZ Pittsburgh Central Keystone Innovation Zone (PCKIZ) PCKIZ Enrollment Questionnaire Allowing new companies to join the PCKIZ and share required documentation Company Name*EIN Number*Company Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary ContactName* First Last TitlePhone*FaxEmail* Enter Email Confirm Email This contact will receive all official KIZ announcements by email.Alternate ContactName First Last TitlePhoneEmail Enter Email Confirm Email CompanyCompany Description*One paragraph summaryCompany Website Type of Technology*Advanced Manufacturing and MaterialsAgriculture and Food ProcessingClean Technology, including energy conversation and environmental sustainabilityCommunications & Information TechnologyDefense/Homeland SecurityEnergy and Environmental TechnologiesEnergy/BiomassFood SciencesHomeland Security HealthcareLife SciencesNanotechOpto/MicroelectronicsPlastics, Wood manufacturingOther (Please describe below, if selected)(Please describe here, if selected "Other")Date Business Established* Start Date in the KIZ* NAICS CodeIs This Business:Woman OwnedMinority OwnedVeteran Ownedcheck all that applyWere You:Created Through KIZ AssistanceKIZ Industry Spin-OutKIZ Academic Spin-Outcheck all that applyPA House District(if known)PA Senate District(if known)Is your company interested in the PCKIZ Internship Program?* Yes No Maybe, tell me more! The PCKIZ Internship Program provides paid interns to qualifying companies within the PCKIZ.File UploadsCompany LogoAccepted file types: png.Please include a company logo file only in PNG format. Dimensions should be 216px wide by 97px high. See our PCKIZ Companies page for examples of how we display your logo. If you provided a company website URL earlier on this form, we will also link from the logo to your website. Lease Agreement*Accepted file types: pdf.Please provide a PDF scan of your lease agreement to verify your location within the PCKIZ. Please call 412-281-0102 with questions.PCKIZ ReportingOnce your application is approved, you will receive notice of the same and Urban Innovation21 will input it into a state KIZ database (KIZ Portal). The KIZ portal administrator will then which will send the Primary Contact an email with a user name and password. Twice a year, all PCKIZ companies are required to login into the PCKIZ Portal and provide the following information in order to be eligible for tax credits, interns and grants. The primary contact will receive an email when the reporting period begins. The list below is the information required for the reporting. It is for your reference only and is not required to be completed now. Employee Count: Projected Annual Revenue: Payroll: EIN Filing Date: Jobs Created: Jobs Retained: New PA Grad Employees: KIZ Tax Credits: KIZ Grants: PA Loans: Other PA Funding: Third Party Grants: Third Party Loans: Investment Capital: Patents filed: Patents Awarded: Software Copyrights Filed: Software Copyrights Awarded: Licenses Granted: Licensing Revenue: New Product Introductions: RDT&E Expenditures NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.