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National/Regional/ Advisory Council Or Small Business Person Of The Year (United States)

This is a Small Business Administration (SBA) small business person of the year application. The form provided here is simply a sample of what the actual Form 898 looks like.

OMB Approval No. 3245-0125

U.S. SMALL BUSINESS ADMINISTRATION

CANDIDATE FOR
NATIONAL/REGIONAL/ ADVISORY COUNCIL
or SMALL BUSINESS PERSON OF THE YEAR

SOCIAL SECURITY NO. _____________________________

NAME:

_____________________________ (First)

_____________________________ (Middle/Initial)

_____________________________ (Last)

POSITION NAME AND ADDRESS OF BUSINESS OR EMPLOYER:

Name _____________________________

Address _____________________________

City _____________________________

State _____________________________

Zip Code _____________________________

TYPE
BUSINESS: _____________________________

PHONE: _____________________________

INDICATE PREVIOUS OR PRESENT FINANCIAL (INCLUDING DEVELOPMENT COMPANY), SURETY BONDS, OR CONTRACTUAL ASSISTANCE WITH SBA. GIVE APPROXIMATE DATES AND TYPE OF ASSISTANCE.

_____________________________

HOME ADDRESS:

Address _____________________________

City _____________________________

State _____________________________

Zip Code _____________________________

SERVICE ON FEDERAL BOARDS, COUNCILS OR COMMISSIONS PRESENT):

_____________________________

IF EMPLOYED BY A STATE GOVERNMENT, IS IT AN ELECTIVE POSITION?

____ YES ____ NO ____ N/A

ARE YOU ON A FEDERAL PAYROLL? ____ YES ____ NO

BIRTH: _____________________________

BIRTH DATE: _____________________________

CONGRESSIONAL DISTRICT: _____________________________

The authority to obtain this information is contained in 5 U.S.C. 301, 15 U.S.C. 634(b), 44 U.S.C., 3101. Routine uses of the information are:

To respond to a request from a member of Congress regarding information about an Advisory Council member.

To disclose information about an Advisory Council Member to general public.

To respond to requests from the General Services Administration.

_____________________________ (Signature)

_____________________________ (Date)

(This must be signed as a condition of the appointment.)

PLEASE NOTE: The estimated burden hours for the completion of SBA Form 898 is 8 minutes per response. You will not be required to respond to this information collection if a valid OMB approval number is not displayed. If you have questions or comments concerning this estimate or other aspect of this information collection, please contact the U.S. Small Business Administration, Chief, Administrative Information Branch, Washington, D.C. 20416 and/or Office of Management and Budget, Clearance Officer, Paperwork Reduction Project (3245-0125), Washington, D.C. 20503.

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