If you are interested in applying for the ROZ program, please fill out the following form. Your information will be reviewed and you will be contacted within 30 days.

Residence Information

Name*

Current Address*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip*

Phone Number*

E-mail Address*

When did you establish this address as your primary residence? (If you have not moved, please type: N/A).*

If currently established in a ROZ county, please provide a copy of proof of home or apartment lease or home ownership and one of the following:

- Acceptance or an offer of permanent employment
- Admission to a licensed practicing profession in Kansas
- Registration of a vehicle in a county designated by the act
- The location at which the individual votes or is registered to vote
- A Kansas driver's license

Note: If not yet established, applicant will be required to submit the necessary documentation.

Upload File:

Upload File:

Upload File:

Please explain your residency status in the county or your plans to move to the ROZ county.

If your current address is located outside of a ROZ county, when do you plan to establish your primary residence within a ROZ county?*

Which ROZ county are you applying for?*

What attracted you to this particular ROZs county?

Note: We have had overwhelming demand for the ROZ tuition reimbursement program in certain Kansas counties, including Chautauqua, Cheyenne, Cloud, Graham, Harper, Hodgeman, Jewell, Kingman, Kiowa, Lincoln, Marion, Mitchell, Pawnee, Pratt, Rawlins, Rooks, Rush, Russell, Sherman, Smith, Thomas, Trego, Wilson and Woodson.

Is the county you are applying for in the list above? *

Yes

No

If you answered “yes,” we would like to visit with you about your preferred county’s current budget status and options that might be available for you. Please send a separate email to roz@kansascommerce.com and include the following information: the county you’re applying for, your anticipated move date and your contact information.

If you have not moved, what needs do you have that must be addressed for you to move to your county of interest?

Job Quality of Schools Access to Healthcare Housing

Recreational Opportunities Hobby/Organization Other

If you chose other, please list your need.

Note: Please provide details regarding your important needs as you consider your transition to a Rural Opportunity Zone county.

Has your primary residence been located outside the State of Kansas for at least 5 years immediately prior to establishing your primary residence within a ROZ county?*

Yes No

Please provide the following details on each of your primary residences within the 5 years immediately prior to establishing your primary residence within a ROZ county.

Address*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip*

Date Established*

Date Vacated*

Did you rent or own your home at this location?

Rent Own

Address

City

State

Zip

Date Established

Date Vacated

Did you rent or own your home at this location?

Address

City

State

Zip

Date Established

Date Vacated

Did you rent or own your home at this location?

Have you or a member of your family ever lived in Kansas?

Yes No

If yes, where?

Income Information

Have you earned more than $10,000 in Kansas source income in any of the 5 years immediately prior to establishing your primary residence within a ROZ county? *

Yes No

If yes, in what years? *

Please check the box below that most accurately reflects your expected annual income range when you have relocated to a ROZ county.*

0-$15,000 $15,001-$30,000 $30,001-$50,000

$50,001-$75,000 $75,001-$100,000 $100,001 +

Education Information

Which of the following most accurately describes your profession or planned profession?*

Engineer Healthcare Utility Education Legal Finance

Accounting Retail Manufacturing Government Student Other

If you chose other, please list your profession.

Do you hold one of the following degrees from an accredited higher learning institution?*

Associate Bachelor Post-graduate Technical Degree No Degree Other

School/University Attended*

Please check the box next to your academic discipline.*

Engineering Nurse Medical Business Education Agriculture Humanities

Vocational Culinary Arts Law Sciences Other

If you answered other, please list your degree.

Student Loan Information

Do you currently have an outstanding student loan balance?*

Yes No

Balance of outstanding student loans

Name of lending institutions

Where did you hear about the Rural Opportunity Zone program?*

How important were the ROZ incentives to your decision to move to a ROZ county?*

Not Important Not very important Important Very Important Most important reason for moving

Would you be willing to speak to the media about your experience with the Rural Opportunity Zone program?

Note: Kansas Dept. of Commerce may request additional information if deemed necessary to verify eligible loan balances and establish a payment process. This information may include but not be limited to transcripts.

Please Note: If you choose the Submit and Print option below, you must be sure to click the Continue button at the bottom of the form once you've printed your copy in order for your nomination to be submitted.