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 National
Small Business Week Award Nominations 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
not 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:
a. Job title:
b. Business name:
c. Business address:
d. Business phone number:
e. Mobile number:
f. Fax number:
g. Business email address:
3. Provide your home address, city/state and zip code.
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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: Penalties for False Statements
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 U.S.C. §§ 1001 and
3571 by imprisonment of not more than five years and/or a fine of not more than $250,000 and
under 15 U.S.C. § 645 by imprisonment of not more than two years and/or a fine of not more
than $5,000;
Signature and Date
______________________________________________________________________________

SBA Form 3300 (08/2017) (Previous Editions Obsolete)

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 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 from disclosure to third parties 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 certain 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

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(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 (08/2017) (Previous Editions Obsolete)