OWNERSHIP/CONTROL DISCLOSURE FORM
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OWNERSHIP/CONTROL DISCLOSURE FORM
This form is a required attachment for institutions submitting an initial Application for Institutional/Programmatic Accreditation. To complete this document, place your cursor in each box and enter the required information. Spaces will expand to accommodate responses.
CAMPUS INFORMATION:
|ABHES ID | |
|NAME OF INSTITUTION | |
|ADDRESS OF INSTITUTION | |
|EMPLOYER IDENTIFICATION NUMBER (EIN) | |
|NAME OF PRIMARY CONTACT | |TITLE: | |
|(SPECIFY DR., MR., MS., MRS.): | | | |
|E-MAIL ADDRESS: | |DIRECT PHONE #: | |
OWNERSHIP STRUCTURE:
The institution is a:
| |Limited Liability Company |
| |Limited Liability Partnership Company |
| |Limited Partnership Company |
| |Non-Profit Organization |
| |Privately Held Business Corporation |
| |Publicly Held Business Corporation |
| |Sole Proprietorship Business |
| |Other |
Attach to this form a detailed description of the ownership structure that includes:
An ownership diagram that sets forth the precise breakdown of the ownership structure including a percentage ownership breakdown/delineation of each entity in the chain of ownership, up to and including the individual(s) who own the ultimate ownership entity in the chain of ownership. The ownership descriptions must include all individuals, partnerships, LLCs, corporations, trusts, or other forms of ownership (for publically traded corporations, this includes shareholders that directly own 10% of the stock as of the date of the application). If the institution is approved to participate in federal student aid programs or has made application for approval, please submit with this form the ownership disclosure information provided the U.S. Department of Education.
Complete applicable sections below:
Limited Liability Company
If Limited Liability Company, list all members:
|Member Name |Percentage of Membership (Ownership Interest) |
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Provide the name, title and contact information for the individual whom ABHES should contact regarding the Limited Liability Company:
| Name and Title |Email Address |Telephone Number |
| | | |
Limited Liability Partnership Company; Limited Partnership Company
If Limited Liability Partnership Company, Limited Partnership Company, list all partners:
|Names of General Partners |Percentage of Partnership (Ownership Interest) |
| | |
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|Names of Limited Partners |Percentage of Partnership (Ownership Interest) |
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Provide the name, title and contact information for the individual whom ABHES should contact regarding the Limited Liability Partnership Company; Limited Partnership Company:
|Name and Title |Email Address |Telephone Number |
| | | |
Non-Profit Organization
If Non-Profit Organization, list the all members and officers of the board of directors/trustees:
|Name |Title |Term of Office |Voting Member? |
| | |End Date |Yes |No |
| | | | | |
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If non-profit organization, attach a copy of the Governance Policy.
If non-profit organization, has this organization been officially recognized by the Internal Revenue Service as an exempt organization under Section 501 © (3), 501 © (4), 501© (5) or 501© (6) of the IRS Code?
|Yes | |No | |
Provide the name, title and contact information for the individual whom ABHES should contact regarding the Non-Profit Organization:
|Name and Title |Email Address |Telephone Number |
| | | |
Privately Held Business Corporation
If Privately Held Business Corporation, list the exact ownership structure, including all levels of subsidiaries under the parent corporation and any subsidiary corporations operating as non-main campuses:
• Provide the ownership percentage breakdown of each entity in the chain of ownership, up to and including the individual(s) who control the ultimate ownership entity in the chain of ownership.
• Provide descriptions for each level that include all individuals, partnerships, LLCs, corporations, trusts, or other forms of ownership stock.)
|Ownership Name and Description |Percentage of Ownership |
| | |
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List all corporate officers:
|Name |Title |
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Publicly Held Business Corporation
If Publicly Held Business Corporation, list the exact ownership structure, including all levels of subsidiaries under the parent corporation and any subsidiary corporations operating as non-main campuses:
• Provide the ownership percentage breakdown of each entity in the chain of ownership, up to and including the individual(s) who control the ultimate ownership entity in the chain of ownership.
• Provide descriptions for each level that include all individuals, partnerships, LLCs, corporations, trusts, or other forms of ownership (for publicly traded corporations, this includes shareholders that directly own 10% of the stock.)
|Ownership Name and Description |Percentage of Ownership |
| | |
| | |
| | |
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| | |
| | |
List all corporate officers:
|Name |Title |
| | |
| | |
| | |
| | |
If publicly held business corporation, the stock is traded on the (specify):
|NASDAQ; NYSE; ASE; OTC; Regional Exchange: | |
Sole Proprietorship Business
If sole proprietorship business, provide legal name and address:
|Name of Ownership |Address |
|Click or tap here to enter text. |Click or tap here to enter text. |
List name, title, and address of individual responsible for operations of the sole proprietorship business that owns the institution.
|Name |Title |Address |
|Click or tap here to enter text. |Click or tap here to enter text. |Click or tap here to enter text. |
| |Ownership Attestation: |
|A. |Has any designated proposed new owner or manager been directly or indirectly employed or affiliated with any school |Yes | |No | |
| |which has lost or been denied accreditation by any accrediting organization during that individual’s period of | | | | |
| |employment or affiliation? | | | | |
|If yes, please attach a statement to this form which details the facts and circumstances surrounding that school’s loss or denial of accreditation. |
|B. |Has any designated owner or manager been directly or indirectly employed or affiliated with any school that has closed|Yes | |No | |
| |without appropriately completing the education or training program for all enrolled students (e.g., an orderly | | | | |
| |teach-out plan/agreement) or entered into bankruptcy during that individual’s period of employment or affiliation? | | | | |
|If yes, please attach a statement to this form which details the facts and circumstances surrounding that school’s closure, bankruptcy or both as |
|applicable. |
|C. |Has any designated owner or manager been directly or indirectly employed or affiliated with any school that has lost |Yes | |No | |
| |or been denied eligibility to participate in Federal Student Financial Aid programs, including those under Title IV of| | | | |
| |the Higher Education Act? | | | | |
|If yes, please attach a statement to this form which details the facts and circumstances surrounding the loss or denial of Title IV eligibility. |
|D. |Is any action pending (e.g. court action, audit, inquiry, review, administrative action), or has action been taken, by|Yes | |No | |
| |any court or administrative body (e.g. federal or state court, grand jury, special investigator, U.S. Department of | | | | |
| |Education, or any state agency), as to any designated proposed new owner or proposed new manager? | | | | |
|If yes, please attach a statement to this form which gives full disclosure of the person(s) and the matters involved. Include a statement of the facts |
|and circumstances surrounding the action identifying the matter (i.e., still under investigation, preliminary decision under appeal, etc.) and the |
|position taken by the owner involved. If the matter is final, provide a copy of the final action documentation. |
|E. |Has any designated proposed new owner or manager served in a similar capacity in any other school where either that |Yes | |No | |
| |individual or the school has been charged or indicted in a civil or criminal forum or proceeding alleging fraud, | | | | |
| |misappropriation, or any criminal act? | | | | |
|If yes, please attach a statement to this form which gives full disclosure of the person(s) and the matters involved. Include a statement of the facts |
|and circumstances surrounding the action identifying the owner and the school which is involved. If the matter is not yet final, please describe the |
|procedural status of the matter (i.e., still under investigation, preliminary decision under appeal, etc.) and the position taken by the owner involved. |
|If the matter is final, provide a copy of the final action documentation. |
I, the undersigned official of the above-named institution, attest that the ownership information provided herein is complete and accurate and includes all information relevant to the ownership/control of the institution. I furthermore understand that any change in the above ownership/control structure must be communicated to the Commission immediately. If the institution changes its legal status, ownership, or form of control mid initial accreditation process, such as after an on-site team visit has been conducted, and prior to an initial grant of accreditation being awarded, the accreditation process will be delayed pending an additional on-site review for Commission consideration, whereupon reapplication and fee may be required.
|AUTHORIZED INSTITUTIONAL REPRESENTATIVE: |
|Name: | |Title: | |
|Signature: | |Date: | |
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