Statement Of Personal History And Qualification Of Management (United States)
This is a Small Business Administration (SBA) statement of personal history and qualification of management. The form provided here is simply a sample of what the actual Form 415A looks like.
U.S. SMALL BUSINESS ADMINISTRATION
STATEMENT OF PERSONAL HISTORY AND QUALIFICATION OF MANAGEMENT
Name of Applicant or Licensee _____________________________
Social Security Number _____________________________
Address
Street _____________________________
City _____________________________
State _____________________________
Zip Code _____________________________
1. First Name in Full _____________________________
Middle Name in Full (If none, so state) _____________________________
Last Name _____________________________
2. Date of Birth (Month, Day & Year) _____________________________
3. Place of Birth (City, State or Foreign Country) _____________________________
4. Citizen of United States? ____ Yes ____ No
5. Starting with present address, list residence addresses for last ten years:
From (Date) _____________________________ To (Date) _____________________________
Street _____________________________
City _____________________________
State _____________________________
Zip _____________________________
From (Date) _____________________________ To (Date) _____________________________
Street _____________________________
City _____________________________
State _____________________________
Zip _____________________________
From (Date) _____________________________ To (Date) _____________________________
Street _____________________________
City _____________________________
State _____________________________
Zip _____________________________
6. Employment and Professional History and Education: Attach a summary of business or professional experience during the last ten years up to and including the present, stating the periods of each primary activity, the names, addresses and nature of business of the firm, concerns or entities with which associated; title, position in such concerns; basic functions and responsibilities; and a summary of your education showing highest level attained (such as high school graduate, some college, one year college, three years college, bachelor's degree, master's degree, etc.-giving, when applicable, name of higher educational institution, your specialization, and date of degree), together with a summary of any special experience or qualification pertinent to the Applicant's management responsibilities.
7. Present Affiliations: Attach a list of all business concerns with which you are presently affiliated as an officer, director, or in any other official capacity, or by way of direct or indirect ownership or control of 10% or more of any class of stock of, or proprietary interest in, such concerns. Show names, addresses, and nature of business of such concerns, and details of relationship and ownership; including the percentage of any stock or proprietary interest owned.
8. List Three Character References: (other than former employers, relatives or fellow Applicants.)
Full Name _____________________________
Home or Business Address _____________________________
City _____________________________
State _____________________________
Zip _____________________________
Business or Occupation _____________________________
Full Name _____________________________
Home or Business Address _____________________________
City _____________________________
State _____________________________
Zip _____________________________
Business or Occupation _____________________________
Full Name _____________________________
Home or Business Address _____________________________
City _____________________________
State _____________________________
Zip _____________________________
Business or Occupation _____________________________
9. Have you ever been, directly or indirectly, the subject of insolvency, bankruptcy, or creditor's rights proceeding, or has any corporation of which you have been an officer, director, or controlling shareholder, been the subject of such proceedings?
____ Yes ____ No (If yes, furnish complete details of such proceedings in a separate exhibit, including if pertinent, the court, title of proceedings, date and docket number, as well as the ultimate disposition thereof.)
10. Have you ever been charged with or convicted of any criminal offense other than a misdemeanor involving minor motor vehicle violations?
____ Yes ____ No (If yes, furnish details as described in Item 9.)
11. Have you, or has any corporation, partnership or other business entity with which you are presently or have heretofore been affiliated (as defined in Item 7) ever been charged with or convicted of a felony or other criminal offense involving dishonesty or breach of trust or found civilly liable or permanently or temporarily enjoined by a court by reason of any act or practice involving fraud or breach of trust?
____ Yes ____ No (If yes, furnish relevant details of any such proceeding in a separate exhibit including the information, indictment or complaint and the court, title of proceeding, date and docket number.)
12. Have you ever been refused a bond? ____ Yes ____ No (If yes, explain.)
13. Are you affiliated with any other Licensee or are you a close relative of any person affiliated with the Applicant or Licensee as described in Section 107.3 of the Regulations?
____ Yes ____ No (If yes, explain.)
14. During any part of the past five years has a request for financial assistance been made to any Federal agency by you or any corporation, partnership or other business entity with which you are presently or have been heretofore affiliated (as defined in Item 7)?
____ Yes ____ No (If yes, furnish details in a separate exhibit, including current status of any assistance received.)
15. Describe any affiliation, past or present, with any other Small Business Investment Company. (See Section 107.702 of the Regulations.)
16. Is any SBA employee or any member of any Advisory Council for the Small Business Administration related to you by blood, marriage or adoption?
Does any SBA employee or member of any such Advisory Council have present or have they had any past, direct or indirect, financial interest in or affiliation with any concern of which you are a director, officer, or owner of 10% or more of any class of its stock or other proprietary interest?
____ Yes ____ No (If yes, list their names, addresses, and relationships on a separate attachment.)
17. If you own or will own 10% or more of the Private Capital of the Licensee, were borrowed funds, used or will they be used in purchasing said Private Capital?
____ Yes ____ No (If yes, attach a statement giving full details, including your net worth, amount borrowed or to be borrowed, source of funds borrowed or to be borrowed, security and/or guarantors and terms of repayment.)
18. Have you or any concern with which you are affiliated directly, or indirectly borrowed funds from or sold securities to any licensed small business investment company?
____ Yes ____ No (If yes, attach a statement giving all pertinent details relative thereto, including the names of all parties to the transaction, the amounts involved, terms, use of proceeds, etc.)
The information on this form will be used in connection with an investigation of your experience and character. It is against SBA policy to provide assistance not in the best interest of the United States, i.e., if there is reason to believe that the effect of such assistance will be to encourage or support directly or indirectly, activities inimical to the security of the United States.
The nature and scope of the investigation may include contact with banks, other financial institutions, individuals, business associates, law enforcement offices, and any other areas which will assist SBA in making an adequate appraisal of your general business reputation, character, management experience and financial soundness. This constitutes the notifications required by section 606 of the Federal Fair Credit Reporting Act.
Under the Privacy Act (5 U.S.C. 552a) requests for information about another party may be denied unless SBA has the written permission of the individual to release the information to the requesters or unless the information is subject to disclosure under the Freedom of Information Act. Note: Any person concerned with the collection of information, its voluntariness, disclosure or routine use under the Privacy Act or requesting information under the Freedom of Information Act may contact the Director, Freedom of Information/Privacy Acts Division, Small Business Administration, 409 3rd Street, S.W., Washington, D.C. 20416, for information about the Agency's procedures of these two subjects.
PLEASE NOTE: The estimated burden for completing this form is 1.5 hours per response. You will not be required to respond to collection of information unless it displays a currently valid OMB approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St., S.W., Washington, D.C. 20416 and Desk Office for Small Business Administration, office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval (3245-0016).
FOR SBA USE ONLY
No. _____________________________
CERTIFICATE: I hereby certify that all information submitted in this SBA Form 415A, and in the Exhibits submitted therewith or in connection therewith, is true and complete to the best of my knowledge and belief. I have read SBA Form 415 "License Application," filed
by _____________________________and the Amendments thereto, and hereby agree that in my proposed capacity as
_____________________________ (show affiliation); I will be bound by the representations made in said Application and Amendments.
Signature _____________________________
Title _____________________________
Date _____________________________