Form SBA Form 3300 SBA Form 3300 Award Nominee Background Form

OMB Control Number 3245-0360
Expiration Date: ______________

SBA Form 3300
Award Nominee Background Form

Instructions:

This form must be completed by:

• Each individual nominated for an award

• All Members of teams nominated for an award

• 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. Answer each question as fully as possible; if it is not applicable, state N/A. Use additional sheets if necessary.

It is important that questions 9-11 be answered completely. An arrest or conviction record will note necessarily disqualify you; however, an untruthful answer will cause your nomination to be denied. If you answer "yes" to 9, 10, or 11, provide 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.

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.

2. Provide the following information:

   1. Job title:

   2. Business name:

   3. Business address:

   4. Business phone number:

   5. Mobile number:

   6. Fax number:

   7. Business email address:

3. Provide your home address, city/state and zip code.

4. Provide your date of birth (month, day and year).

5. Are you a United States citizen?

6. If you are not a United States Citizen, are you a lawful permanent resident alien (include alien registration number)?

7. Are you presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts or financial assistance by any Federal agency?

8. Have you been notified of any delinquent Federal taxes for which the liability remains unsatisfied?  Federal taxes are considered delinquent if the tax liability is finally determined and the taxpayer is delinquent in making payment.

9. Are you presently under indictment, on parole or probation? (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).

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?

I authorize the Small Business Administration 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 USC 1001 by imprisonment of not more than five years and/or a fine of not more than $10, 000; under 15 USC 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 USC 1014 by imprisonment of not more than thirty years and/or a fine of not more than $1,000,000.

Signature and Date

______________________________________________________________________________

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 as part of the nomination package, 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. Responding to this request for information is voluntary. However, failure to provide the requested information may affect SBA’s ability to make a decision regarding your eligibility for an award.

The estimated burden for completing this form is 15 minutes. However, the total estimated time for completing the nomination package (Form 3300, the award specific nomination, and all other information outlined in the “Awards Nominations Guidelines”), is 90 minutes. This estimate includes the time for reviewing the instructions, gathering and compiling data, and submitting the package. You are not required to respond to any collection of information unless it displays a currently valid OMB control number (3245-0360). 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. Submit them to the location identified in the nomination guide.

Privacy Act (5 U.S.C. § 552a)

Anyone can request copies of an individual’s personal information that SBA has in in its files 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 certain collected information is listed in the systems of record notice for SBA 28, Small Business Person and Advocate Awards-, which was last published in the Federal Register at 74 FR 14889.

SBA Form 3300 (08/2015) (Previous Editions Obsolete)