Identification and Credit Information - Individuals

OMB Control Number 1024-0233

Expiration Date: ________

IDENTIFICATION AND CREDIT INFORMATION (Individual)

Identification

Name

Address

Telephone Number

Fax Number

Education, Degrees, Licenses, Designations, Special Skills

Name of Current Employer

Address

Nature of Business

Dates of Employment

Title of Position Most Recently Held

Description of Duties and Responsibilities (Include number of people supervised)

Proposed Role in Lease Operations

Qualifications for that Role

Estimated Time per Week Dedicated to that Role

Credit Information

1. List any Foreclosures, Bankruptcies, Transfers in Lieu of Foreclosure and/or Work-Out/Loan Modification Transactions during the past 10 years. (If none, so indicate). Attach an explanation of circumstances, including resolution, bankruptcy plan, and/or other documentation as appropriate.

2. Describe any fines or penalties levied by government agencies during the past 10 years. (If none, so indicate)

3. Describe any pending litigation or current lawsuits which if adversely resolved would materially impact the financial position of the Applicant.

Paperwork Reduction Act Statement. We collect this information under the authority of Title IV of the National Parks Omnibus Management Act of 1998 (Pub. L. 105-391). We use this information to evaluate proposals received in response to leasing opportunities. Your response is required to obtain or retain a benefit. We estimate that it will take you 1 hour to complete this form. This estimate includes time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form.

You may send comments on the burden estimate or any aspect of this form to the Information Collection Clearance Officer, National Park Service, 1849 C Street, NW, (2601), Washington, DC 20240. We may not collect or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB control number.

4. Attach:

a. Personal Financial Statement documenting assets and liabilities.

b. Credit Reports for the individual(s) from a major credit reporting company such as Equifax, Experian, and Dunn & Bradstreet.