Business Identification and Credit Information

OMB Control No. 1024-0233

Expiration Date: XX/XX/2017

1. Business Identification and Credit Information:

Individual or Sole Proprietor

Name of Individual and Tradename, if any
Address
Telephone Number
Fax Number
Email Address
Contact Person
Tax ID #
Years in Business
Current Value of Business
Role in Providing Business Services

Credit Information

Has Applicant ever defaulted from or been terminated from a management contract or lease, or been forbidden from contracting by a public agency or private company?  Yes  No

If YES, provide full details of the circumstances.

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.

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)

Name of Property	City State	Property Type	Approximate Loan Amount	Lender	Year of Event

Attach an explanation of circumstances, including resolution, bankruptcy plan, and/or other documentation as appropriate.

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

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

Attach:

Personal Financial Statements

Business Financial Statement for most recent 2 years

Current credit reports for the individual and business (if available for the business) from a major credit reporting company such as Equifax, Experian, or Dunn & Bradstreet.

Attach Resumes of Individual as follows:

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

2. Business IDENTIFICATION and Credit Information:

Corporation, Limited Liability Company, Partnership, or any Joint Venture

Complete separate form for the submitting entity and the parent entity (include all partners in a joint venture).

Name of Entity and Tradename, if any
Address
Telephone Number
Fax Number
Email Address
Contact Person
Title
Tax ID#
State of Formation
Date ofFormation

Ownership	Percentage of Ownership	Current Value of Investment
Names and Addresses of those with controlling interest and key principals of business
Total Interests Outstanding and Types

Officers and Directors or General Partners or Managing Members or Venturers	Address	Title and/or Affiliation

Credit Information

Has Applicant ever defaulted from or been terminated from a management contract or lease, or been forbidden from contracting by a public agency or private company?  Yes  No

If YES, provide full details of the circumstances.

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)

Name of Property	City State	Property Type	Approximate Loan Amount	Lender	Year of Event

Attach an explanation of circumstances, including resolution, bankruptcy plan, and/or other documentation as appropriate.

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

Describe any pending litigation or current lawsuits (other than those covered adequately by insurance) which if adversely resolved would materially impact the financial position of the Applicant.

Attach:

Business Financial Statements for the two most recent fiscal years (audited, if available) with all notes.

Personal Financial Statements for all general partners in a partnership, managing members of a limited liability company, and all venturers in a joint venture.

Current credit reports for the entity and key principals, from a major credit reporting company such as Equifax, Experian, or Dunn & Bradstreet.

Attach Resumes of Principals as follows:

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