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
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
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.