Form SBA Form 898 SBA Form 898 Advisory Committee Membership Nominee Information Form

Advisory Committee Membership

Nominee Information Form

3. Employer’s Name:

     

OMB Control No: 3245-0124

Expiration Date: 08/31/ 2008

1. I wish to serve as a member of the following SBA advisory committee (pick one):

Audit & Financial Management National Advisory Council District Advisory Council _______________

National Women’s Business Council Veterans Business Affairs Small Business Development Center Board

Small Business Regulatory Fairness Board, Region ____ Other ______________________________

4. Industry/NAICS:

     

City/State/Zip:

     

Employer’s Address:

     

Title/Position:

     

5. Is this a small business per 13 C.F.R. §121? yes no

6. Are you or any member of your household an applicant for or recipient of any SBA assistance? An applicant or recipient of SBA assistance includes a sole proprietor, partner, officer, director, or stockholder with a 10% or more interest in an entity, whether profit or non-profit, that applied for or received SBA assistance. yes no (if “yes” check all that apply)

Contract or Grant Guaranteed Loan Surety Bond Guarantee

SBIC License SBLC Status HUBZone Certification

Certificate of Competency or Size Determination 8(a) or Small Disadvantaged Business Certification

Express decision to compromise or defer possible litigation or other adverse action

Other Assistance: _______________________

8. Character Information:

Yes No Are you presently under indictment, on parole or probation?

Yes No Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation (including offenses that have been dismissed or discharged)?

Yes No Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation (including judgments withheld pending probation for any criminal offense other than a minor motor vehicle violation)?

Yes No Have you ever had a professional or business license suspended or revoked?

Yes No Have you ever been suspended or debarred from Federal assistance, including procurements?

Yes No Have you ever defaulted on a Federal loan or Federal-assisted financing?

Yes No Have you ever been the subject of suspension action or revocation of privilege to conduct business with SBA under 13 C.F.R. §103 or other SBA regulations.

I understand I am applying for membership to the above named advisory committee and that the information I provide may be verified by SBA and used to help determine my eligibility for advisory committee membership. I hereby certify that the information provided in this form is true and accurate.

9. If answered “yes” to any part of question 7 or 8 please explain (attach additional pages as necessary):

     

     

     

     

Signature

Date:

     

2. Applicant’s Name:

     

Home Address:

     

City/State/Zip:

     

Phone:

     

Email:

     

Fax:

     

Place of Birth (City/State):

     

Date of Birth:

     

Print Name

7. Are you or any member of your household a party to litigation involving SBA? yes no

ADVISORY COMMITTEE MEMBERSHIP NOMINEE INFORMATION (OMB Control No. 3245-0124)

NOTICES REQUIRED BY LAW

Purpose of Form:

SBA will use the information collected on this form to make a character and eligibility decision regarding individuals nominated to the agency's Advisory Boards. The information is required in order for SBA to have sufficient information to determine whether nominees meet eligibility requirements for membership on an SBA advisory council, including whether a conflict of interest exists between a nominee and SBA or between a business in which a nominee is a stakeholder (e.g. owner, director, shareholder, employee, nominee's business, etc) and SBA prior to the appointment of a council member, and whether a nominee meets the character standards that have been set. The information collected may be checked against criminal history indices, including those maintained by the Federal Bureau of Investigation. Response to this form is voluntary; however failure to provide the information would inhibit SBA's ability to determine whether a nominee is eligible for appointment.

Paperwork Reduction Act (44 U.S.C. Chapter 35):

The estimated burden for responding to this request for information, including time to compile the information, is one hour per response. You are not required to respond to this collection of information unless it displays a currently valid OMB Approval (Control) number. If you have any questions concerning the estimated burden for this form you may contact the U.S. Small Business Administration, Chief – AIB, 409 3^rd Street, S.W., Washington, DC 20416; or Desk Officer for 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 retrievable by individual identifiers, such as name. Requests for information about another party may be denied unless SBA has the written permission of the individual to release the information to the requestor or unless the information is subject to disclosure under the Freedom of Information Act.

Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social security number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name and other personal identifiers are, however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for it to make a character determination. In determining whether an individual is of good character, SBA considers the person's integrity, candor, and disposition toward criminal actions. Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 U.S.C. § 636 (a)(1)(B). Further, for all forms of assistance, SBA is authorized to make all investigations necessary to ensure that a person has not engaged in acts that violate the Act or the Small Business Investment Act, 15 U.S.C. § 634(b)(1l) and 687b(a). For these purposes, you are asked to voluntarily provide your social security number to assist SBA in making a character determination and to distinguish you from other individuals with the same or similar name or other personal identifier.

When this information indicates a violation of potential violation of law, whether civil, criminal, or administrative in nature, SBA may refer it to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility for or otherwise involved in investigation, prosecution, enforcement or prevention of such violations. See, SBA Privacy Act System of Records – SBA 3, Advisory Council Files, at 70 FR 33930 (June 10, 2005) for other published routine uses.

SBA Form 898 (08-08) Previous Editions Are Obsolete