SBA Form 1010-Busi 8(a) Business Development Program Application

8(a) BUSINESS DEVELOPMENT PROGRAM APPLICATION

SBA Form 1010 - Business

NOTICE OF CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS:

Under Title 18 U.S.C. § 1001 and Title 15 U.S.C. § 645, any person who misrepresents a business concern’s status as an 8(a) Program participant, or makes any other false statement in order to influence the certification process in any way, or to obtain a contract awarded under the preference programs established pursuant to section 8(a), 8(d), 9 or 15 of the Small Business Act, or any other provision of Federal Law that reference Section 8(d) for a definition of program eligibility shall be: (1) Subject to fines and imprisonment of up to 5 years, or both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 and imprisonment of up to 10 years, or both, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4) Ineligible for participation in programs conducted under the authority of the Small Business Act.

SIGNATURE REQUIRED. Your signature on this form indicates that you fully understand all questions and that you certify, under the risk of committing perjury, that all responses and documents are truthful and accurate.

1. There is a one-time eligibility restriction for 8(a) Participants. This one time eligibility applies to both the certified 8(a) firm and the socially and economically disadvantaged individual(s) upon whom eligibility was based on. Once the 8(a) participation ends, neither the firm nor the individual(s) will be eligible for the program again.

2. You must obtain official copies of all corporate documents. Articles, licenses, permits, etc. must be current and approved by the state or states where you conduct business. www.sba.gov/content/registering-your-business-state-agencies

3. You must obtain a free DUNS number from Dunn and Bradstreet either online or by calling 1-866-705-5711 or visiting https://fedgov.dnb.com/webform. DUNS numbers are unique nine-digit identification numbers for each physical location of your business. DUNS numbers are required for firms applying to the 8(a) BD program.

4. You must obtain a free Tax Identification Number (TIN) or Employer Identification Number (EIN) from the Internal Revenue Service (IRS) http://www.sba.gov/content/obtain-your-federal-business-tax-id-ein. However, many sole proprietorships use the owner’s Social Security Number (SSN) and this is acceptable.

5. You must have an active DSBS Profile (Dynamic Small Business Search) in the Federal government’s contractor database using the System for Award Management (SAM) – www.sam.gov. This profile is required prior to applying to the 8(a) BD Program.

6. Your firm must demonstrate potential for success by demonstrating it has been in business in its primary industry for two years, or you will need to request a waiver of this requirement. If the business concern has not yet generated revenues, you will not be successful obtaining a waiver. For more information about “potential for success”, please see 13 CFR § 124.107. Please note that firms owned by Alaska Native Corporations, Tribes, Native Hawaiian Organizations, and Community Development Corporations have special rules regarding potential for success. See 13 CFR §§ 124.109(c)(6), 124.110(g), and 124.111(f).

7. You must complete your application online and mail documents as required.

Getting Started with the 8(a) BD Application

• Online Application – http://www.sba.gov/8abd

• Rules and Regulations 13 CFR Part 124 – www.ecfr.gov

• Helpful Tips for applying to the 8(a) Business Development Program: http://www.sba.gov/gcclassroom

• Your local SBA District Office and SCORE Offices, Small Business Development Centers, Women’s Business Centers, Veteran’s Business Outreach Center and Procurement Technical Assistance Centers provide ‘free’ guidance for 8(a) applicants.

ARE YOU READY TO APPLY?

INFORMATION ABOUT THE 8(a) BUSINESS DEVELOPMENT PROGRAM APPLICATION

Authority to Collect Information: The U.S. Small Business Administration (SBA) is authorized by sections 8(a) and 7(j) of the Small Business Act and codified at 13 CFR Part 124 to determine eligibility for the 8(a) Business Development (BD) Program. All applicants seeking 8(a) certification must complete this Form 1010 and all other applicable forms. SBA uses all information submitted to the 8(a) BD Program to determine the applicant’s eligibility for the program.

Disclosure of Information: SBA will keep confidential the application you submit and the supporting documentation you provide with this application, to the extent required by law. SBA’s collection of information in the application process is necessary to determine eligibility for participation pursuant to statutory and regulatory requirements. SBA maintains any sensitive information it collects in compliance with the Privacy Act. For more information regarding the protection of such information refer to SBA’s Privacy Act Systems of Record Notice at http://www.sba.gov/content/privacy-act-systems-records, specifically SBA 30: Servicing and Contracts System/Minority Enterprise Development Headquarters Repository.

Use of Representatives: If you use a third party (person or organization) to complete or to help you complete this application and the third party is not an employee of the applicant business, you must also fill out the Representatives and Fees section that is a part of this Form 1010.

IMPORTANT DEFINITIONS

Affiliation may be present when there is common management, ownership, or control between the applicant firm and another business concern or when there are contractual relationships, prior relationships, familial ties, common investments with, or economic dependence on other business concerns. For more information on affiliation and SBA’s Size Regulations please see 13 CFR § 121.103. Additional guidance can be found at www.sba.gov/content/affiliation

AIT (American Indian Tribe) is any Indian tribe, or community of Indians, including any ANC, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians, or is recognized as such by the State in which the tribe, band, nation, group or community resides. All applicant firms owned by an AIT must complete the SBA Form 1010-AIT, except those firms owned by ANCs.

ANC (Alaska Native Corporation) is any Regional Corporation, Village Corporation, Urban Corporation, or Group Corporation organized under the laws of the State of Alaska in accordance with the Alaska Native Claims Settlement Act, as amended (43 U.S.C. 1601, et seq.). All applicant firms owned by an ANC must complete the SBA Form 1010-ANC.

CDC (Community Development Corporation) is a nonprofit organization responsible to residents of the area it serves which has received financial assistance under 42 U.S.C. 9805, et seq. All applicant firms owned by a CDC must complete the SBA Form 1010-CDC.

CCR (Central Contractor Registration) was consolidated by the System for Award Management (SAM). To be awarded contracts by Federal government agencies both current and potential government vendors must be registered with SAM.

DSBS is Dynamic Small Business Search. A DSBS profile is required in the database for all firms seeking to do business with the Federal government as a small business and is a prerequisite for applying into the 8(a) BD Program. A current profile is required prior to applying into the 8(a) BD Program. You can access the DSBS through SAM.

DUNS numbers are nine digit identification numbers assigned by D&B. DUNS numbers are not assigned by the Federal government. The DUNS number assignment is free for all businesses and is required to register in SAM. Learn more by visiting http://fedgov.dnb.com/webform. Before you submit this Form 1010 application for certification in the 8(a) BD Program, you must obtain a DUNS number.

Immediate Family Member means father, mother, husband, wife, son, daughter, brother, sister, grandfather, grandmother, grandson, granddaughter, father-in-law, and mother-in-law.

Key Employee is an employee who, because of his/her position in the concern, has critical influence in or substantive control over the operations or management of the concern.

NAICS is the North American Industry Classification System. The firm’s NAICS code is a six-digit number that describes the service(s) and/or product(s) the firm can perform or provide. Learn more by visiting the U.S. Census Bureau’s NAICS Internet site at http://www.census.gov/epcd/www/naics.html.

NHO (Native Hawaiian Organization) is any not-for-profit community service organization serving and controlled by, Native Hawaiians in the State of Hawaii and whose business activities will principally benefit Native Hawaiians.

Primary NAICS Code is that which best describes the primary business activity of the 8(a) BD applicant or Participant. In determining primary NAICS code designations SBA considers the distribution of receipts, employees and costs of doing business among the different industries in which business operations occurred for the most recently completed fiscal year. SBA may also consider other factors, such as the distribution of patents, contract awards, and assets. More information about NAICS codes and size standards is available at the Small Business Size Standards website http://www.sba.gov/services/contractingopportunities/sizestandardstopics/index.html.

Principal is an owner of at least 10% of the applicant firm or a director, management member, partner, officer or key employee.

SAM (System for Award Management) is the Official U.S. Government system that consolidated the capabilities of several systems including CCR. More information about SAM is available at www.sam.gov. Registration in SAM.gov is free.

Size is determined by calculating average annual receipts for firms whose primary NAICS code has a dollar-based size standard and by calculating the average number of employees for firms whose primary NAICS code has an employee-based size standard. All 8(a) certified firms must qualify as a small business concern. See 13 CFR Part 121 for additional guidance regarding size.

SECTION I

BUSINESS PROFILE

Legal Name of Applicant firm: ______________________________________________

(Trade name or D.B.A.): ___________________________________________________________________

1. Has this firm previously been certified as an 8(a) Participant?  Yes  No

2. Has this firm (under any name) or any of its owners, board of directors, officers, managers, or key employee ever:

• withdrawn an 8(a) application or  Yes  No

• been denied 8(a) certification or  Yes  No

• been terminated or early graduated from 8(a) participation or  Yes  No

• voluntarily withdrawn from 8(a) participation or  Yes  No

• been debarred or suspended by any Federal entity.  Yes  No

3. Is the firm operating as a broker?  Yes  No

4. Has the firm generated any revenue?  Yes  No

5. Name and Title of the 51% Owner(s) Claiming Social and Economic Disadvantage:

Name: Title:

Business Main Telephone: ( )________________ Fax: ( )__________________

Mobile:( )________________ Website:____________________________________

Business Address:_____________________________________________________________________________

City: _________________________ County: _______________ State: ________________ Zip: ______________

E-mail: ____________________________________________@ ____________________________

Applicant Firm’s Primary Point of Contact and Title: _______________________________________________________

Mailing Address for Point of Contact (if different from above): ___________________________________________

City: _________________________ County: _______________ State: ________________ Zip: ______________

6. Type of Business:

 Manufacturing  Retail Dealer  Non-Professional service

 Construction  Professional Service  Wholesaler

 Concession  Franchise

7. Date Applicant Firm Was Established:

8. Date of Ownership for Principal(s):

9. How did Principal(s) acquire this firm (check all that apply):

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Started this business Bought existing business Inherited Business Merger or Consolidation

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Other (explain) ______________________________________________

10. Primary NAICS Code: 11. Employee/Taxpayer Identification Number:

12. DUNS Number: 13. DSBS Number:

14. Is the Applicant Firm:

 For-Profit Business  Non-Profit Business

15. Legal Structure:

 Sole Proprietorship  Corporation

 Partnership  Limited Liability Company

 Other (explain)

16. Has this Applicant Firm ever existed under different ownership, a different type of ownership, or a different name?

 Yes  No

If Yes, explain: __________________________________________________________________

17. Average number of employees during the past 12 months? ___________________________

18. Percentage of revenues earned in the primary NAICS Code during the most recently completed fiscal year: _______________%

19. Has the Applicant Firm or any of its affiliate received a formal SBA size determination?  Yes  No

If yes, identify the SBA office, the determination date, and provide a copy of the determination.

_________________________________________________________________________________________

_____________________________________________________________________________________________

20. Is the Applicant Firm owned by an individual or by another entity? (check all that apply):

 Individual(s) %_____________

Applicant firms at least 51% or more unconditionally owned by an AIT, ANC, NHO, or CDC must also submit Form 1010-AIT, Form 1010-ANC, Form 1010-NHO or Form 1010-CDC, as applicable.

 Other Firm(s) %_____________

 AIT %____________________

 ANC %____________________

 CDC %____________________

 NHO %____________________

SECTION II

BUSINESS MANAGEMENT AND ADMINISTRATION

A. Ownership and Control

1. Provide the following information for all owners, directors, management members, partners, and officers:

(Use additional sheets if necessary)

Name	Percentage of Ownership in Applicant Firm	Position in Applicant Firm	Does This Individual Hold the Highest Position in the Applicant Firm? (Y/N)	Does This Individual Have Another Job Outside the Applicant Firm? (Y/N)	How Many Hours Per Week Does This Individual Devote to the Applicant Firm?	Is This Individual Using His/Her Disadvantaged Status to Qualify the Applicant Firm? (Y/N)

2. Do any of the persons listed above have ownership with another firm that was previously admitted in the 8(a) BD Program? If yes, attach a detailed explanation including the individual’s ownership interest, title, other company name and description of the person’s function/role in that other company.

 Yes

 No

3. Do any of the persons listed above work for any other company that has a relationship with this Applicant

Firm (e.g,. ownership interest, shared office space, financial investments loans, shared or leased equipment, office

space, personnel sharing, etc.)? If yes, attach a detailed explanation of the relationship.

 Yes

 No

4. Do any of the persons listed above perform management/supervisory functions for another company? If, yes

attach a detailed explanation of the individual’s title, the other company’s name and a description of the person’s function/ role in that other company.

 Yes

 No

SECTION II

BUSINESS MANAGEMENT AND ADMINISTRATION

B. Business Information

Is the Applicant Firm delinquent in filing any applicable business tax returns? If yes, please provide the year of delinquency and an explanation.	 Yes	 No
Does the Applicant Firm have any outstanding delinquent Federal, state or local financial obligations (including delinquent SBA loans) or liens filed against it? If yes, provide information about any tax liens or unsatisfied judgments, evidence of repayment arrangements and proof of compliance with repayment arrangements.	 Yes	 No
Does the Applicant Firm have any existing management, joint venture, indemnity, consulting, distributorship, licensing, teaming, trust or franchise agreements? If yes, include copies of these agreements.	 Yes	 No
Have there been any changes in ownership of the Applicant Firm in the past two years? If yes, identify the prior owner(s), ownership percentage, and dates of ownership.	 Yes	 No
Does the Applicant Firm currently have an ownership interest in any other business? If yes, provide for each other business or organization the following information: (1) the name and address; (2) the type/structure of business or organization; (3) the names of the owner and board of directors; (4) the Primary NAICS code; (5) the nature of the relationship; (6) the percentage of ownership by the Applicant Firm; and (7) a statement as to whether the other business is a current or former 8(a) BD Program Participant.	 Yes	 No
Does any other business or other organization have a 10% or more ownership interest in the Applicant Firm? If yes, provide for each other business or organization the following information: (1) the name and address; (2) the type/structure of business or organization; (3) the names of the owner and board of directors; (4) the Primary NAICS code; (5) the nature of the relationship; (6) the percentage of ownership by the other business or organization; and (7) a statement as to whether the other business is a current or former 8(a) BD Program Participant.	 Yes	 No
Does the Applicant Firm lease or use office space or other facilities from any other business? If yes, do any principals of the Applicant Firm have a financial or any other interest in the owner of the leased facility? If yes, provide the name of the other business and the name of the principal who has an interest in the owner of the leased facility.	 Yes	 No
Do any outside entities or individuals provide financial or bonding support, licenses or required professional certification? If yes, provide the names, the nature of assistance (in the case of licenses and professional certifications, include a copy of the license and/or certification) and copies of agreements governing that relationship, if applicable.	 Yes	 No
Is the 8(a) Applicant the highest compensated individual in the firm? If no, provide an explanation of how this arrangement is in the best interest of the Applicant Firm.	 Yes	 No
Did you hire an outside consultant to assist with your 8(a) application (e.g., attorney, accountant, appraiser, agent, or other representative)? If yes, complete the representative information at the end of this form.	 Yes	 No
Is the Applicant Firm a defendant in any pending lawsuit? If yes, summarize its interest in the suit, the claims, the current status, and provide a copy of the complaint, answer, and/or counterclaim filed in the suit.	 Yes	 No
Has the Applicant Firm filed for bankruptcy or insolvency within the past 7 years? If yes, provide details and a copy of the bankruptcy court’s final order or discharge.	 Yes	 No
Do the assets (machinery, contracts, equipment, etc.) of a previously certified 8(a) BD Program Participant constitute 50% or more of the Applicant Firm’s assets? If yes, provide the name of the previous 8(a) Participant and documentation pertaining to the acquisition of these assets.	 Yes	 No
Has the Applicant Firm earned revenues in its primary NAICS code for at least two years as evidenced by business tax returns submitted with the application? If no, you will need to seek SBA’s approval for a waiver of the “potential for success” requirement. For more information regarding a waiver, please see 13 CFR § 124.107. Please also note that Applicant Firms owned by an ANC, AIT, NHO or CDC must meet the applicable requirements set forth at 13 CFR §§ 124.109(c)(6), 124.110(g), or 124.111(f) in order to fulfill the “potential for success” requirement.	 Yes	 No
Is the Applicant Firm currently co-located with another business, organization or entity at any of its business locations, or does it share any of the following with any other business, organization, or entity: telephone number, P.O. Box, office space, yard, warehouse, facilities, equipment, or office staff? If yes, please provide a copy of the agreement and terms of the arrangements. Does any immediate family member of the owner, officer, director, manager, or key employee of the applicant firm own a business that has a contractual relationship with the Applicant Firm? If yes, provide the family member’s name, relationship, firm name, type of business, DUNS number, and the family member’s role in the other firm and this Applicant Firm. Indicate if the other firm(s) are, or have ever been, 8(a) Participants.	 Yes  Yes	 No  No

Note: For each “yes” response to the preceding questions 1 -16, you must attach a detailed explanation.

SECTION III

SUPPORTING DOCUMENTATION

8(a) Applicants must provide the documents requested below. Please check the appropriate box identifying whether the document is provided, does not exist, or does not apply. For those documents not provided, please provide an explanation identifying the document and the reason it is not provided.

YES	NO	N/A	CHECKLIST OF DOCUMENTS REQUIRED
			A list of current and past Federal and non-Federal awarded contracts within the last 12 months. Include award date, agency/customer name, NAICS code, a description of work, and dollar value.
			Interim or year-end balance sheet and profit and loss statement no older than 90 days from the application date.
			Copies of the last three years of the Applicant Firm’s filed Federal tax returns including all schedules and attachments.
			Copy of the firm’s current Certificate of Good Standing (for Corporations and LLCs, if applicable), or similar document, from the state where the applicant firm is incorporated/organized.
			Copies of the last three years of filed Federal tax returns, including all schedules and attachments, for all of the Applicant Firm’s acknowledged affiliates. SBA criteria for defining affiliates should be carefully reviewed and can be found at 13 CFR § 121.103.
			Copies of all stock certificates (front and back), stock ledgers, /registers, any transmutation agreements (for community property states), and any voting agreements.
			Copies of all business bank account signature cards. In lieu of this, a letter from the bank indicating all individuals with signatory authority on all bank accounts will suffice.
			Copies of the business and special licenses under which the Applicant Firm operates. This includes industry related licenses. Include the name(s) of the qualifying party/individual.
			Copies of the Applicant Firm’s current loan agreements, including lines of credit and shareholder loan(s). Provide all loan sources, amounts, purposes of money loaned, name(s) of any persons/firms securing the loan and the name(s) of those guaranteeing the loan.
			Copies of buy/sell agreements, shareholder agreements or other similar arrangements which may impact the unconditional ownership of the disadvantaged individuals.
			List of all contributions or transfers of assets to/from the Applicant Firm and to/from any of its owners over the past two years. Include dollar value, from whom transferred, to whom transferred, relationship between the parties, date of transfer and copies of any supporting documents and agreements.
			Copies of all management and joint venture agreements, to include any mentor protégé agreements, teaming agreements, indemnity agreements and consulting agreements, including agreements for assistance in completing this 8(a) BD application.
			Copies of all statements of bonding ability from the Applicant Firm’s surety specifying single job limit and aggregate limit, if applicable for the firm’s primary industry (construction or engineering).
			A completed Individual Information Form (SBA Form 1010-IND), SBA Form 912, and all supporting documents required by those forms for each individual owning at least 10% or more of the business and each director, management member, partner and officer.
			A completed Personal Financial Statement (SBA Form 413) for all individuals claiming economic disadvantage to qualify the Applicant Firm and for those individuals’ spouses.
			Copies of the Applicant Firm’s governing documents, as applicable (see below): For Corporations: Articles of Incorporation (original and current version), Bylaws (current version), and the most recent Stockholder and/or Board Member Meeting Minutes showing the election of officers and directors, if applicable. For Limited Liability Companies: Articles of Organization (original and current version), Operating Agreement (current version); resolution or other documentation designating officers, directors, members representative, management committee members, and/or general managers as required by the business concern’s governing documents (if not included in the Operating Agreement). For Partnerships: Partnership Agreement. For Sole Proprietorships: Copies of Fictitious Business Name Filing.

SIGNATURE PAGE

Read the following paragraphs carefully. Your signature below indicates acceptance and understanding of these conditions.

1. Payment of any fee or gratuity to SBA employees is illegal and will subject the parties of such a transaction to prosecution.

2. Applicant agrees to allow SBA access and the right to examine corporate records including, but not limited to, books, documents, papers and other material considered by SBA to be necessary.

3. SBA, in its sole discretion, may at any time request clarification of information contained in this application or any other documents submitted as part of the application process, and may request additional information or documents as it deems appropriate to complete its review of the application.

4. If the applicant firm fails to provide any requested information or documents, SBA may presume that disclosure of the information would demonstrate that the applicant firm is not eligible for 8(a) BD Program certification.

CERTIFICATIONS: By signing this form, I certify that I have reviewed the response to every question on this form, all attachments and all supporting documents required by this form, and that all responses and documents are true and complete to the best of my knowledge, and that I understand that SBA is relying on this information in making its determination of my company’s eligibility for 8(a) BD Program certification.

Form must be signed by the President, CEO, Proprietor, Management Member, General Partner or individual holding the highest position for the applicant business.

______________________________________________________

Signature (Individual holding the highest position for the firm)

______________________________________________________

Print Name Date

Mailing Addresses

If your firm is located in one of the states: MA, ME, NH, CT, VT, RI, NY, PR (Puerto Rico), VI (US Virgin Islands), NJ, PA, MD, VA, WV, DC, DE, GA, AL,NC, SC, MS, FL, KY, TN, NY Send documents electronically via email to (8aPhiladelphia@sba.gov) or mail hard copy documents to: US Small Business Administration DPCE Central Office Duty Station / 8(a) Applications Parkview Towers 1150 First Avenue 10th Floor, Suite 1001 King of Prussia, PA 19406

If your firm is located in one of the states: IL, OH, MI, IN, MN, WI, TX, NM, AR, LA, OK, MO, IA, NE, KS, CO, WY, ND, MT, UT, SD, CA, HI, GU (Guam), NV,  AZ, WA, AK, ID, OR Send documents electronically via email to (8aSanFrancisco@sba.gov) or mail hard copy documents to: Small Business Administration DPCE Central Office Duty Station / 8(a) Applications 455 Market Street, 6th Floor San Francisco, CA 94105

REPRESENTATIVES AND FEES

Important! It is not necessary to hire and pay another person to prepare this or any other 8(a) BD Program application. The SBA District Offices and SCORE Counselors, Small Business Development Centers, Women’s Business Centers, Veteran’s Business Outreach Center and Procurement Technical Assistance Centers offer assistance to 8(a) applicants. However, if the applicant firm does pay another person, the fees paid must be reasonable in light of the services performed. See 13 CFR § 124.4. The fee charged by any agent or representative for assisting the applicant in obtaining 8(a) BD Program certification cannot be contingent upon the applicant receiving certification. The agent or representative may be excluded under 13 CFR Part 103, or suspended or debarred under 2 CFR Part 180 or 48 CFR Subpart 9.4. For good cause (as defined at 13 CFR § 103.4), the AA/BD may initiate proceedings to suspend or revoke a packager's, agent's or representative's privilege to assist applicants obtain 8(a) certification, assist Participants obtain 8(a) contracts, or any other assistance to support program participation. The AA/BD may send a show cause letter requesting the agent or representative to demonstrate why the agent or representative should not be suspended or proposed for revocation, or may immediately send a written notice suspending or proposing revocation, depending upon the evidence in the administrative record.

List the names of attorneys, accountants, appraisers, agents or other representatives who assisted in the preparation or filing of the application. Indicate the amount of fees, bonuses, commissions or expenses paid or due. SBA reserves the right to require, at a later date, a full itemization by representatives of actual services rendered. Attach additional pages if necessary.

NAME AND OCCUPATION OF REPRESENTATIVE	DESCRIPTION OF SERVICES	TOTAL FEES PAID OR DUE

CERTIFICATION: By signing this form, we certify under penalty of criminal prosecution that all information on this form and any attached additional pages, and all responses on the application, including all supporting documents, is true and complete to the best of our knowledge, and that we understand that SBA is relying on this information in making its determination of the reasonableness of the fees charged and the applicant business concern’s eligibility for 8(a) BD Program certification.

Applicant:

___________________________ ____________________________ _______________________

Signature Print Name Date

(Individual holding the highest position for the firm)

Representative(s)

1. ___________________________ ____________________________ _______________________

Signature Print Name Date

Name of Employer _____________________________________________________________________

2. ___________________________ ____________________________ _______________________

Signature Print Name Date

Name of Employer _____________________________________________________________________

3. ___________________________ ____________________________ _______________________

Signature Print Name Date

Name of Employer _____________________________________________________________________

PLEASE NOTE: The estimated burden for completing this form, including reading the instructions and gathering the information, is 1 hour for initial application and each annual update. (A submission for reconsideration is estimated to require approximately 30 minutes). You are not required to respond to any 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/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.