SBA Form 3312 Women's Business Outreach Center of the Year

OMB Control Number 3245-0360
Expiration Date: ______________

National Small Business Week SBA Form 3312, Women’s Business Outreach Center 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. WBC Information:

   1. Name:

   2. Address:

   3. Phone number:

   4. Email address:

   5. Website URL:

2. WBC Director Information:

1. Name:

2. Phone number:

3. Email address:

3. Host organization information:

   1. Organization name:

   2. Executive director name:

4. Nominator Information (if applicable):

1. Nominator name:

2. Title:

3. Address:

4. Phone number:

5. Email address:

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

5. Provide a biography for the WBC director:

6. Provide a description of the WBC’s services:

7. Provide a narrative of a WBC counselor who has excelled in providing counseling, training and other program services to small businesses:

8. Provide a narrative of a success story relating to a particular business served by the WBC:

9. Provide a narrative of how the WBC has worked with the local SBA District Office as a champion for SBA products and services including effective amplification of the SBA mission and priorities and strong education efforts about the SBA and its programs to small businesses:

Answer each of the following questions in 400 words or less.

10. Provide a business profile including the WBC mission statement, target market, and types of services offered, including any specialized programs or services. The profile should include performance on key milestones for the last three years and address how the center is being Smart in efficiently delivering services including using online technology; Bold in delivering programs reaching both start up and growth oriented businesses, and; Accessible in serving a diverse community (including services in multiple languages, hours and location of services, utilizing community partners to deliver services across the entire service area.)

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 3312 (08/2015)