SBA Form 3301 Small Business Person of the Week

OMB Control Number 3245-0360
Expiration Date: ______________

National Small Business Week
SBA Form 3301, Small Business Person of the Year

Instructions:

This form must be completed by the nominee or by the nominator. 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.

1. Lead Nominee Information:

   1. Name:

   2. Title:

   3. Business name:

   4. Business address:

   5. Business phone number:

   6. Business email address:

2. Co-nominee(s) Information (Note: you may nominate up to 3 additional co-nominees per business. Each co-nominee must fill out the SBA Form 3300):

   1. Name(s):

   2. Title(s):

   3. Email address(es):

3. Nominator Information (if you are nominating yourself, write n/a):

   1. Nominator name:

   2. Title:

   3. Address:

   4. Phone number:

   5. Email address:

4. Provide the nominee(s) percentage of ownership or stock owned in the small business.

5. How many years has the nominee’s business been operational (minimum 3 years)?

6. How many employees does the business currently have?

7. Does the business have a website? If yes, list the URL:

8. To assess the financial performance of the business for the last 3 calendar years, fill out the chart below.

Financial Summary
Year	2012	2013	2014
Number of Employees
Total Sales
Net Profit (Before Tax)
Total Assets
Total Liabilities
Net Worth

Answer each of the following questions in 200 words or less.

9. Provide a biography for the nominee(s):

10. Has the business received SBA assistance (e.g. SBA loan, SCORE counseling, SBDC assistance, WBC assistance contracting or Emerging Leader Initiative)? If yes, please explain (include the amount and date of financial assistance received if applicable):

11. Describe the nominee’s business, including areas served:

12. Has the business expanded to additional locations, grown in square footage or increased web traffic since its founding? If yes, please explain.

13. Based on the financial chart provided above, please explain in more detail the business’s year to year changes in financial health (e.g. sales, net profit, net worth) and number of employees.

14. What products or services does the business provide and how does the business fit a niche not addressed by the competition in the marketplace?

15. Does the business export? If yes, please explain.

16. Has the nominee had a financial, physical, legal, or other crisis while in business? Please explain the situation and actions taken to resolve it.

17. Does the nominee contribute money, time or resources to his or her community or charitable causes? If yes, please explain.

18. Is the nominee a member of a council, board or club providing support and services to his or her community? If yes, please explain.

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.

Paperwork Reduction Act Notice:

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.

You are not required to respond to any collection of information unless it displays a currently valid OMB control number (3245-0360). The estimated burden for completing this form is 1 hour and 45 minutes, including the time for reviewing the instructions, and gathering and compiling data. Combined with the time for completing the Form 3300, the total estimated time to prepare and submit the nomination package for each nominee is 90 minutes. Comments on this burden estimate 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 COMPLETED FORMS TO OMB. Submit them to the location indicated in the nomination guide.

SBA Form 3301 (08/2015)