This preview shows pages 1–2. Sign up to view the full content.
This preview has intentionally blurred sections. Sign up to view the full version.View Full Document
Unformatted text preview: United States of America SMALL BUSINESS ADMINISTRATION STATEMENT OF PERSONAL HISTORY OMB APPROVAL NO.3245-0178 Expiration Date: 2/28/2013 Please Read Carefully: SBA uses Form 912 as one part of its assessment of program eligibility. Please reference SBA Regulations and Standard Operating Procedures if you have any questions about who must submit this form and where to submit it. For further information, please call SBA's Answer Desk at 1-800-U-ASK-SBA (1-800-827-5722), or check SBA's website at www.sba.gov . Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code) SBA District/Disaster Area Office Amount Applied for (when applicable) File No. (if known) 1. Personal Statement of: (State name in full, if no middle name, state (NMN), or if initial only, indicate initial.) List all former names used, and dates each name was used. Use separate sheet if necessary. First Middle Last 2. Give the percentage of ownership or stock owned 3. Date of Birth (Month, day, and year) 4. Place of Birth: (City & State or Foreign Country) U.S. Citizen? YES NO If non- U.S. citizen provide alien registration number: Address: Present residence address: From: To: Home Telephone No. (Include Area Code): Business Telephone No. (Include Area Code): Address: Most recent prior address (omit if over 10 years ago): From: To: PLEASE SEE REVERSE SIDE FOR EXPLANATION REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION. YOU MUST INITIAL YOUR RESPONSES TO QUESTIONS 5,7,8 AND 9. IF YOU ANSWER "YES" TO 7, 8, OR 9, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHER MISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANY OTHER PERTINENT INFORMATION. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, 7. Are you presently under indictment, on parole or probation?...
View Full Document