Fillable SBA 898 - SBA 898 Copy (U.S. Small Business Administration)

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SBA 898 - SBA 898 Copy (U.S. Small Business Administration)

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SBA Form 898 (08-08)
Previous Editions Are Obsolete
Advisory Committee Membership
Nominee Information Form
OMB Control No:
3245-0124
Expiration Date:
11/30/ 2011
1. I wish to serve as a member of the following SBA advisory committee (pick one):
Audit & Financial Management National Advisory Council District Advisory Council
National Women’s Business Council Veterans Business Affairs Small Business Development Center Board
Small Business Regulatory Fairness Board, Region
Other
2. Applicant’s Name:
3. Employer’s Name:
Home Address:
Employer’s Address:
City/State/Zip:
City/State/Zip:
Phone:
Fax:
Title/Position:
Email:
4. Industry/NAICS:
Date of Birth:
5. Is this a small business per 13 C.F.R. §121? yes no
6. Are you or any member of your household an applicant for or recipient of any SBA assistance? An applicant or recipient of
SBA assistance includes a sole proprietor, partner, officer, director, or stockholder with a 10% or more interest in an entity,
whether profit or non-profit, that applied for or received SBA assistance. yes no (if “yes” check all that apply)
Contract or Grant Guaranteed Loan Surety Bond Guarantee
SBIC License SBLC Status HUBZone Certification
Certificate of Competency or Size Determination 8(a) or Small Disadvantaged Business
Certification Express decision to compromise or defer possible litigation or other adverse action
Other Assistance:
7. Are you or any member of your household a party to litigation involving SBA?
yes no
8. Character Information:
Yes No Are you presently under indictment, on parole or
probation?
Yes No Have you ever been charged with or arrested for
any criminal offense other than a minor motor
vehicle violation (including offenses that have
been dismissed or discharged)?
Yes No Have you ever been convicted, placed on pretrial
diversion, or placed on any form of probation
(including judgments withheld pending probation
for any criminal offense other than a minor motor
vehicle violation)?
Yes No
Have you ever had a professional or
business license suspended or revoked?
Yes No
Have you ever been suspended or
debarred from Federal
assistance, including
procurements?
Yes No Have you ever defaulted on a Federal
loan or Federal-assisted financing?
Yes No Have you ever been the subject of
suspension action or revocation of
privilege to conduct business with SBA
under 13 C.F.R. §103 or other SBA
regulations.
9. If answered “yes” to any part of question 7 or 8 please explain (attach additional pages as necessary):
I understand I am applying for membership to the above named advisory committee and that the information I provide may be
verified by SBA and used to help determine my eligibility for advisory committee membership. I hereby certify that the information
provided in this form is true and accurate.
Signature
Date:
Print Name
click to sign
signature
click to edit
SBA Form 898 (08-08)
Previous Editions Are Obsolete
ADVISORY COMMITTEE MEMBERSHIP NOMINEE INFORMATION (OMB Control No. 3245-0124)
NOTICES REQUIRED BY LAW
Purpose of Form:
SBA will use the information collected on this form to make a character and eligibility decision regarding individuals nominated to the
agency's Advisory Boards. The information is required in order for SBA to have sufficient information to determine whether nominees meet
eligibility requirements for membership on an SBA advisory council, including whether a conflict of interest exists between a nominee and
SBA or between a business in which a nominee is a stakeholder (e.g. owner, director, shareholder, employee, nominee's business, etc) and
SBA prior to the appointment of a council member, and whether a nominee meets the character standards that have been set. The
information collected may be checked against criminal history indices, including those maintained by the Federal Bureau of Investigation.
Response to this form is voluntary; however failure to provide the information would inhibit SBA's ability to determine whether a nominee is
eligible for appointment.
Paperwork Reduction Act (44 U.S.C. Chapter 35):
The estimated burden for responding to this request for information, including time to compile the information, is one hour per response.
You are not required to respond to this collection of information unless it displays a currently valid OMB Approval (Control) number. If you
have any questions concerning the estimated burden for this form you may contact the U.S. Small Business Administration, Chief – AIB, 409
3
rd
Street, S.W., Washington, DC 20416; or Desk Officer for 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 retrievable by
individual identifiers, such as name. Requests for information about another party may be denied unless SBA has the written permission of
the individual to release the information to the requestor or unless the information is subject to disclosure under the Freedom of
Information Act.
Under the provisions of the Privacy Act, you are not required to provide your social security number. Failure to provide your social security
number may not affect any right, benefit or privilege to which you are entitled. Disclosures of name and other personal identifiers are,
however, required for a benefit, as SBA requires an individual seeking assistance from SBA to provide it with sufficient information for it to
make a character determination. In determining whether an individual is of good character, SBA considers the person's integrity, candor, and
disposition toward criminal actions.
Additionally, SBA is specifically authorized to verify your criminal history, or lack thereof, pursuant to section 7(a)(1)(B), 15 U.S.C. § 636
(a)(1)(B). Further, for all forms of assistance, SBA is authorized to make all investigations necessary to ensure that a person has not engaged
in acts that violate the Act or the Small Business Investment Act, 15
U.S.C. § 634(b)(1l) and 687b(a). For these purposes, you are asked to voluntarily provide your social security number to assist SBA in making a
character determination and to distinguish you from other individuals with the same or similar name or other personal identifier.
When this information indicates a violation of potential violation of law, whether civil, criminal, or administrative in nature, SBA may refer
it to the appropriate agency, whether Federal, State, local, or foreign, charged with responsibility for or otherwise involved in
investigation, prosecution, enforcement or prevention of such violations. See, SBA Privacy Act System of Records – SBA 3, Advisory Council
Files, at 70 FR 33930 (June 10, 2005) for other published routine uses.
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SBA 898 - SBA 898 Copy (U.S. Small Business Administration)

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Completed 25 June 2021

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