Form 4063a Individual Application for Approval of Official or Senio

OMB No. for NCUA 3133-0121

Expiration Date: November 30, 2017

Individual Application for Approval of Official or Senior Executive Officer

Public reporting burden for this collection of information is estimated to average 2 hours for biographical information. This estimate includes time to gather and maintain data in the required form, to review instructions, and to complete the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Office of Examination and Insurance, National Credit

Union Administration, 1775 Duke Street, Alexandria, Virginia 22314 and to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20503. An organization or a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.

General Information and Instructions

This Individual Application for Approval of Official or Senior Executive Officer (application) is used by individuals in conjunction with other corporate filings to the appropriate regulatory agency. This report is not a stand alone document.

Preparation

Use of this application is not mandatory. Alternative formats, if used, however, must provide all requested information, including the certification of

correctness and that the Privacy Act Notice has

been read. All questions must be answered with complete and accurate information that is subject to verification. If the answer is “none,” “not applicable,” or “unknown,” so state. Answers of “unknown” should be explained. The questions are not intended to duplicate information supplied on another form or in an exhibit; a cross reference to the information is acceptable. If this application is used, questions should be answered in the space provided. Use additional sheets as necessary. If the application is not complete, the Regional

Director may either request additional information or return the application. If you are a foreign national or a United States citizen who currently resides in a foreign country, additional information will be necessary.

If an applicant has been convicted of any criminal offense involving dishonesty, breach of trust, or money laundering, or has agreed to enter into a pretrial diversion or similar program in connection with a prosecution of such offense (12 U.S.C. § 1785), the applicant must obtain approval from the NCUA before being employed in or becoming an institution affiliated party with a federally insured credit union.

Each applicant must report promptly any material change in the biographical information and/or financial condition that occurs during the review period for this application.

NCUA Form 4063a Page 1 of 8

INDIVIDUAL APPLICATION FOR APPROVAL OF OFFICIAL OR SENIOR EXECUTIVE OFFICER

This is filed with respect to:

Charter/Insurance Number Name of Subject Institution, Location

Type of Filing Position

Change in Official or Senior Executive Officer Director

Committee Member Senior Executive Officer

BIOGRAPHICAL REPORT

1. Personal Information

1. Name:

Last First Middle (no initials)

2. Residence:

Street Address

City State ZIP Code

3. If at residence less than five years, list addresses and dates occupied for past five years.

Date From	Date To	Number and Street, City, State, ZIP Code

d.	Date of birth:	e.	Place of birth:
	Month/Day/Year		City, State, Country

f.	Social Security Number: (Please read the Privacy Act Notice contained in the Credit	g.	Citizenship: Country (Date, if Naturalized)
	Report and Background Investigation Authorization section before answering this question.)
h.	If not a U.S. citizen, Passport No.:		Home Country ID No.:
	Father’s name:		Mother’s maiden name:

Immigration File No.:

9. Telephone and fax numbers where you may be reached during business hours:

Area Code--telephone Number Fax Number

9. Trade names and/or other names used in place of given name and period of and reason for use.

Name	Period of Use	Reason for Use

2. Employment Record

1. List employment in reverse chronological order for the last five years. If not employed due to retirement, please indicate date retired and employment information prior to retirement date.

Date From	Date To	Name/Location (City, State)/ Nature of Business	Position Held/ Nature of Duties	Reason for Leaving

2. Have you ever been dismissed or asked to resign from any past employment, including a less than honorable discharge from military service? Yes No If “yes,” complete the following:

Employer’s Name/ Address/Telephone	Position	Date of Discharge	Explanation

3. Education and Professional Credentials

1. List each diploma/degree from high schools, colleges, universities, or other schools.

School’s Name/Location	From	To	Degree

2. List each professional license or similar certificate you now hold or have held (for example, Attorney, Physician, CPA, NASD or SEC registration).

License	Issuing Authority	Date Issued	Expiration

4. Business and Financial Institution Affiliations

1. List any businesses (corporation, partnership, joint venture, trustee) with which you are associated.

Business Name/Location	Nature of Business	Position/Relationship	Percent Ownership	From

2. List any financial institution where you are currently or have previously been an official, employee, director, committee member or owner (10% ownership or more of any class of stock).

Business Name/Location	Nature of Business	Position/Relationship	Percent Ownership	From	To

4. Business and Financial Institution Affiliations - Continued

3. Are you in the process of being considered for a senior executive officer or director position by any other regulatory agency?

Yes No

If “yes,” provide the name of the agency and the institution or holding company.

4. Legal and Related Matters

CRIMINAL OFFENSE GUIDELINES

The Federal Credit Union Act, Subchapter II, section 205(d), requires that, except with the written consent of the NCUA Board, no person shall serve as director, officer, committee member, or employee of an insured credit union who has been convicted or who is hereafter convicted, of any criminal offense involving dishonesty or breach of trust. To assist the NCUA Board in making a determination of the fitness of a person who is selected to serve, the specific information below must be furnished.

(If “yes” is answered to any item in (a)-(g) below, describe the situation in detail, including the name and location of the institution, business, or parties involved, the date(s), nature of the charge/association/proceeding, name and address of court involved, and the disposition.)

1. Have you ever been the subject, in your individual or corporate capacity, of a prior or current application or notice that was filed in final form and subsequently denied, withdrawn, or otherwise failed to obtain favorable action, or other regulatory matter and/or administrative action pertaining to any federal or state financial institution?

Yes No

2. Have you been associated as a senior executive officer, director, or principal shareholder (owning 10% or more of the outstanding stock) with any insured depository institution or financial institution holding company that has been subject to any enforcement action or have you been personally subject to a prohibition or removal order, civil money penalty, or other enforcement action?

Yes No

3. Have you been associated as a senior executive officer, director, or principal shareholder of any insured depository institution that: (1) failed, (2) received financial assistance from a financial institution depository agency (e.g., NCUSIF, FDIC, Resolution Trust Corporation, or former Federal Savings and Loan Insurance Corporation), or (3) was a merger partner with an institution that received financial assistance from a financial institution depository agency?

Yes No

5. Legal and Related Matters – Continued

4. Have you ever been involved, or are you currently involved, in any lawsuit, formal or informal investigation, examination, or administrative proceeding (excluding routine or customary audits, inspections, and investigations) issued against, entered into by, or involving you or a company with which you are or were associated that may result in or resulted in any sanction, fine, monetary damage, loss of right or benefit, revocation of license, agreements, undertakings, consents or orders with any federal or state court, any department, agency, or commission of the U.S. government or state, municipal, or foreign government entity?

Yes No

5. Have you or any business or enterprise with which you have been associated as an officer, including a senior executive officer, director, or principal shareholder of 10% or more of outstanding stock, filed for bankruptcy or forfeited property?

Yes No

6. Has a claim pertaining to a fidelity bond ever been filed against you or have you ever been denied coverage under a fidelity bond?

Yes No

7. Are there any civil suits or any material legal or administrative proceeding pending against you?

Yes No

8. Have you ever defaulted on a personal loan, loan to your company, or loan in which you were a guarantor?

Yes No

If “yes,” provide complete details, including direct and indirect debt terms, defaulted amount, and lender.

9. Have you or any business or enterprise with which you are or were associated as an officer, including a senior executive officer, director or principal shareholder (owning 10% or more of the outstanding stock), been the subject of any law enforcement agency's charge, arrest, indictment, conviction, conviction whereby the record was subsequently expunged, or have you pleaded nolo contendere to any criminal matter (other than minor traffic violations)?

Yes No

If "yes," complete the following:

Name/Type of Business	Relationship/ Stock Owned	Nature of Charge/Proceeding	Date of Charge	Jurisdiction Location	Disposition	Date

5. Additional Information

Present any other information you believe is important to evaluate your filing. If you are involved in the organization of a new institution, discuss your specific role.

Privacy Act Notice

A copy of this document is provided to the NCUA as required under various statutes and implementing regulation(s). To the extent that it contains personal and financial information about persons, the information may be subject to the Privacy Act of 1974 (5 U.S.C. § 552a) which provides safeguards for personal information. The NCUA may, at its discretion, disclose any or all of the information obtained concerning you to other regulatory agencies or other law enforcement or governmental agencies, in connection with the investigation of a possible violation of any federal or state statute or when such release is determined to be in the best interest of the appropriate regulatory agency and consistent with the public interest and applicable law. The NCUA may obtain information about you from any and all sources without limitation. These documents are considered confidential and generally are exempt from public disclosure under the authority of 5 U.S.C. § 552, relating to a personnel, medical, or similar record, including a financial record, or any portion thereof, the disclosure of which would constitute a clearly unwarranted invasion of personal privacy.

I understand the NCUA may conduct extensive checks into my background, experience, and related matters in conjunction with my application or filing. I certify that the information contained in the biographical report and/or financial report has been carefully examined by me and is true, correct, and complete.

I also certify that I read the Privacy Act Notice provided in the attached Credit Report and Background Investigation Authorization. I further certify that the information provided in this application has been carefully examined by me and is correct, complete, and made in good faith. Any misrepresentation or omission of a material fact constitutes fraud in the inducement and may subject me to legal sanctions provided by 18 U.S.C.

§1001 and §1006.

I understand that the NCUA may disapprove any applicant they determine whose employment or affiliation with the credit union is not in the best interest of the membership of the credit union or of the public.

Certification:

Signature

Print or type name

Title (if applicable)

Signed this day of ,

INDIVIDUAL APPLICATION FOR APPROVAL OF OFFICIALOR SENIOR EXECUTIVE

OFFICER – Continued

CREDIT REPORT AND BACKGROUND INVESTIGATION AUTHORIZATION

The National Credit Union Administration (NCUA) may evaluate the competence, experience, character, and integrity of any individual who is to serve as an official, employee, or committee member of a newly chartered or troubled federally insured credit union. This is in accordance with section 212 of the Federal Credit Union Act (12 USC §1790a).

NCUA may disapprove any individual whose employment it believes will not be in the best interest of the credit union or of the public. To assist in the evaluation process, NCUA may obtain and review an individual’s credit report. NCUA may also verify information contained in this application and, if deemed necessary, may also conduct an investigation into my background.

Last First Middle

Street Address City State Zip Code

Social Security Number Date of Birth

My signature below authorizes NCUA to obtain a copy of my credit report.

Signature Date

PRIVACY ACT NOTICE

The Privacy Act of 1974 (Public Law 93-579) requires that you be advised as to the legal authority, purpose and uses of the information solicited by this form. Pursuant to Sections 104, 205(d), and 212 of the Federal Credit Union Act, the information in this form is requested for the purpose of completing the investigation required for a new federal credit union or proposed officials of a credit union declared to be in a troubled condition status. The information in this form is for use in determining the competence, experience, character and integrity of the applicant. NCUA may conduct a more involved background check as part of the approval process. You will be notified if we need to resolve a concern after concluding the background check. This form may be disclosed to any of the following sources: a congressional office in response to your inquiry to that office; an appropriate federal, state, or local authority in the investigation or enforcement of a statute or regulation; or employees of a federal agency for audit purposes. Failure to complete this form or omission of any item of information, except for disclosure of your social security number, may result in a delay in the processing of this application. In accordance with Section 792.68 of NCUA's regulations, you are not required to furnish your social security number on this form. Your social security number, if voluntarily provided, will be used to more easily verify the information required by this form. No penalty will result to you as a senior executive officer or as a compensated or volunteer official or to the credit union if you do not provide your social security number.