Sba Form 3300 – Fill Out and Use This PDF

					OMB Control Number 3245 -0360
					Expiration Date: 12/31/2010
			Please Read Carefully- Print or Type
	United States of America		This form must be completed by:
	SMALL BUSINESS		(1) Each individual nominated for an award
	ADMINISTRATION		(2) All Members of teams nominated for an award
			(3) The official representative of		a small business nominated for an award
	Award Nomination Form		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.
1. State name in full, if no middle name, state (NMN), or if initial			List all forms of SBA funded assistance received (e.g., SBDC, SCORE, WBC,
only, indicate initial. List all former names used, and dates each			guaranteed loan, contract, etc.) and the city and state where assistance was
name was used.			received.
Use separate sheet if necessary.
First	Middle	Last
2. Name and Address of small business company			Amount and date of financial assistance			File No. (if known)
			received or applied for (if applicable)
Firm Name :
Street :
			5. Give the percentage of ownership or stock owned
City, State and Zip Code:
			In the small business
Business Telephone No. (Include A/C):
Cell No. (Include A/C):
Fax No. (Include A/C):
E-Mail Address:
			6. Date of Birth (Month, Day, and Year)
Job Title:
			7. Place of Birth (City & State or Foreign Country)
3. Present residence address:			8. U.S. Citizen?	__ YES	__ NO
From:
To:			If No, are you a Lawful Permanent resident alien: __ YES __ NO
Address:			If non-U.S. citizen provide alien registration no.: _____________
			9. Congressional District:

IT IS IMPORTANT THAT THE NEXT THREE QUESTIONS 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 10, 11, 0R 12, FURNISH 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.

10. Are you presently under indictment, on parole or probation? __ YES __ NO

(If yes, indicate date parole or probation is to expire).

11.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).

__ YES __ NO

12. 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? __ YES __ NO

13 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	Title	Date

SBA Form 3300 (7-07)

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, 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.

The estimated burden for completing this form is 15 minutes per response. However, the total estimated time for completing the nomination package, including the time for reviewing the instructions, gathering and compiling data, and completing the package is 2 hours. You are not required to respond to any collection of information unless it displays a currently valid OMB control number. 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.

Privacy Act (5 U.S.C. § 552a)

Any person can request to see or get copies of any personal information that SBA has in his or her file 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 this collection of information is listed in the systems of record notice published in the Federal Register at 69 FR 58597,58624(9/30/2004).