Form 4062a Individual Application for Approval of Official or Senio

OMB Control No. 3133-0121

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.

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.

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

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.

NCUA Form 4063a

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.

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
a. Name:
Last

First

Middle (no initials)

b. Residence:
Street Address

City

State

ZIP Code

c. 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

f.

City, State, Country

Social Security Number:

g.

(Please read the Privacy Act Notice contained in the Credit
Report and Background Investigation Authorization section
before answering this question.)

h. If not a U.S. citizen, Passport No.:

Country (Date, if Naturalized)

Home Country ID No.:

Father’s name:

Mother’s maiden name:

Immigration File No.:

NCUA Form 4063a

Citizenship:

Page 2 of 8

INDIVIDUAL APPLICATION FOR APPROVAL OF OFFICIALOR SENIOR EXECUTIVE
OFFICER - Continued
i.

Telephone and fax numbers where you may be reached during business hours:
Area Code--telephone Number

j.

Fax Number

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
a. 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

b. 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

NCUA Form 4063a

Position

Date of
Discharge

Page 3 of 8

Explanation

INDIVIDUAL APPLICATION FOR APPROVAL OF OFFICIALOR SENIOR EXECUTIVE
OFFICER - Continued
3. Education and Professional Credentials
a. List each diploma/degree from high schools, colleges, universities, or other schools.
School’s Name/Location

From

To

Degree

b. 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
a. List any businesses (corporation, partnership, joint venture, trustee) with which you are associated.
Business Name/Location

Nature of Business

Position/Relationship

Percent
Ownership

From

b. 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

NCUA Form 4063a

Nature of Business

Position/Relationship

Page 4 of 8

Percent
Ownership

From

To

INDIVIDUAL APPLICATION FOR APPROVAL OF OFFICIALOR SENIOR EXECUTIVE
OFFICER – Continued
4. Business and Financial Institution Affiliations - Continued
c.

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.

5. 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.)
a. 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
b. 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
c.

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

NCUA Form 4063a

Page 5 of 8

INDIVIDUAL APPLICATION FOR APPROVAL OF OFFICIALOR SENIOR EXECUTIVE
OFFICER – Continued
5. Legal and Related Matters – Continued
d. 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
e. 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
f.

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

g. Are there any civil suits or any material legal or administrative proceeding pending against you?
Yes
No
h. 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.

i.

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

NCUA Form 4063a

Relationship/
Stock Owned

Nature of
Charge/Proceeding

Page 6 of 8

Date of
Charge

Jurisdiction
Location

Disposition

Date

INDIVIDUAL APPLICATION FOR APPROVAL OF OFFICIALOR SENIOR EXECUTIVE
OFFICER – Continued
6. 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

NCUA Form 4063a

day of

,

Page 7 of 8

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

Street Address

Middle

City

Social Security Number

State

Zip Code

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.

NCUA Form 4063a

Page 8 of 8