Form SBA FORM 3300 SBA FORM 3300 AWARD NOMINATON FORM

OMB Control Number 3245 ______
Expiration Date: ________
Please Read Carefully- Print or Type

United States of America
SMALL BUSINESS
ADMINISTRATION
Award Nomination Form

1. State name in full, if no middle name, state (NMN), or if initial
only, indicate initial. List all former names used, and dates each
name was used.
Use separate sheet if necessary.
First

Middle

This form must be completed by:
(1) Each individual nominated for an award
(2) All Members of teams nominated for an award
(3) The official representative of a small business nominated for an award
The completed form must be submitted with the nomination package as noted
in the award guidelines. Each question must be answered as fully as possible;
if it is not applicable, state N/A. Use additional sheets if necessary.

List all forms of SBA funded assistance received (e.g., SBDC, SCORE, WBC,
guaranteed loan, contract, etc.) and the city and state where assistance was
received.

Last

2. Name and Address of small business company
Firm Name :
Street :
City, State and Zip Code:
Business Telephone No. (Include A/C):
Cell No. (Include A/C):
Fax No. (Include A/C):
E-Mail Address:
Job Title:

Amount and date of financial assistance
received or applied for (if applicable)

File No. (if known)

5. Give the percentage of ownership or stock owned by the nominee
In the small business

6. Date of Birth (Month, Day, and Year)

7. U.S. Citizen?

__ YES

__ NO

3. Current home address:
From:
To:

If No, are you a Lawful Permanent resident alien:

Address:

If non-U.S. citizen provide alien registration no.: _____________

__ YES

__ NO

8. Congressional District:

IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS BE ANSWERED COMPLETELY. AN ARREST OR CONVICTION RECORD WILL
NOT NECESSARILY DISQUALIFY YOU; HOWEVER, AN UNTRUTHFUL ANSWER WILL CAUSE YOUR NOMINATION TO BE DENIED.
IF YOU ANSWER ”YES” TO 10, 11, 0R 12, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES,
SENTENCES, WHETHER MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S)
UNDER WHICH CHARGED, AND ANY OTHER PERTINENT INFORMATION.

9. Are you presently under indictment, on parole or probation?
__ YES __ NO
(If yes, indicate date parole or probation is to expire).

10. Have you ever been charged with and/or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which
have been dismissed, discharged, or not prosecuted. (All arrests and charges must be disclosed and explained on an attached sheet).
__ YES __ NO

11. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending
probation, for any criminal offense other than a minor vehicle violation? __ YES __ NO

12.I authorize the Small Business Administration’s Office of Inspector General to request criminal record information about me from criminal justice
agencies for the purpose of determining my eligibility for a small business recognition award and to participate in the related activities, including
programs authorized by sections 4(h) and 8(b)(1)(A)(iv) of the Small Business Act, 15 U.S.C. 633(h) and 637(b)(1)(A)(iv).

CAUTION: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil
penalties, and a denial of program participation or other benefits awarded by the agency. A false statement is punishable under 18 U.S.C. 1001 by
imprisonment of not more than five years and/or a fine of not more than $10,000; under 15 U.S.C. 645 by imprisonment of not more than two years
and/or a fine of not more than $5,000; and, if submitted to a Federally insured institution, under 18 U.S.C. 1014 by imprisonment of not more than
thirty years and/or a fine of not more than $1,000,000.
Signature
Title
Date

SBA Form 3300 (7-07)

NOTICES REQUIRED BY LAW
Paperwork Reduction Act (44 U.S.C. 3501 et seq.)
SBA will use the information collected on this form, along with other information submitted by
award nominees, to determine the nominee’s eligibility for a particular small business award; to
identify any actual or apparent conflict of interest and, to make eventual award determinations.
The estimated burden for completing this form is 15 minutes per response. However, the total
estimated time for completing the nomination package, including the time for reviewing the
instructions, gathering and compiling data, and completing the package is 2 hours. You are not
required to respond to any collection of information unless it displays a currently valid OMB
control number. Comments on these burden estimates should be sent to the U.S. Small
Business Administration, Chief, AIB 409 3rd St.,SW, Washington, DC 20416, and Desk Officer
for the U.S. Small Business Administration, Office of Management and Budget, New Executive
Office Building, Room 10202, Washington, DC 20503. DO NOT SEND FORMS TO OMB.
Privacy Act (5 U.S.C. § 552a)
Any person can request to see or get copies of any personal information that SBA has in his or
her file when that file is retrieved by individual identifiers, such as name or social security
number. SBA will protect an individual’s personal information to the extent permitted by law,
including the Freedom of Information Act, 5 U.S.C. § 552, and the Privacy Act of 1974, 5 U.S.C.
§ 552a. However, as a routine matter information collected may be disclosed as follows: (a) to
the news media for public disclosure of the name, address, and biography of award recipients;
(b) to communicate with State and local governments about the status of a particular nominee;
(c) to an individual nominee’s Congressional office when that office is inquiring on the
individual’s behalf; (d) to Agency volunteers, interns, judges, experts and contractors who need
access to the records in order to perform an award related activity; and (e) to the Department of
Justice (DOJ); the court, adjudicative body, or a dispute resolution body when any of the
following is a party to litigation or has an interest in such litigation:
(1) The agency or any of its components;
(2) An agency employee in his or her official capacity;
(3) An agency employee in his or her individual capacity where DOJ has agreed to represent
the employee; or
(4) The United States Government, where the agency determines that litigation is likely to affect
the agency or any of its components.
Before making any disclosures SBA must determine that the use of the records is relevant and
necessary to the litigation, and disclosure of the records is for a purpose that is compatible with
the purpose for which the records were collected.
Additional information regarding the retention and disclosure of this collection of information is
listed in the systems of record notice published in the Federal Register at 69 FR
58597,58624(9/30/2004).