Ownership/Control Disclosure Form

ACCREDITING BUREAU OF HEALTH EDUCATION SCHOOLS 7777 Leesburg Pike, Suite 314 N. · Falls Church, Virginia 22043 Tel. 703/917.9503 · Fax 703/917.4109 · E-Mail: [email protected] 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.

Name of Institution: Employer Identification Number (EIN) Address of Institution:

Ownership Structure:

The institution is a: Sole Proprietorship Business Privately Held Business Corporation Publicly Held Business Corporation Non-Profit Organization Limited Liability Partnership Company Limited Partnership Company Other

Complete applicable sections below:

Sole Proprietorship Business If sole proprietorship business, provide legal name and address:

Name of Ownership Address

List name, title, and address of individual(s) responsible for operations of the sole proprietorship business that owns the institution.

Name Title Address

OWNERSHIP/CONTROL DISCLOSURE FORM Revised 2016 (7/7/16) 1 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 (for publicly traded corporations, this includes shareholders that directly own 10% of the stock.)

List all corporate officers: Name Title

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.)

List all corporate officers: Name Title Voting Member (Yes/No)

If publicly held business corporation, the stock is traded on the (specify): NASDAQ; NYSE; ASE; OTC; Regional Exchange:

OWNERSHIP/CONTROL DISCLOSURE FORM Revised 2016 (7/7/16) 2 Non-Profit Organization If Non-Profit Organization, list the all members and officers of the board of directors/trustees: (Continue on additional sheet if necessary.) Voting Member Name Title Yes No

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

Limited Liability Partnership Company, Limited Partnership Company, Or Other If Limited Liability Partnership Company, Limited Partnership Company or Other:

Please explain below:

Alternate Contact Information:

The following will be used in the event ABHES must contact the institution/program and is unsuccessful using the published contact information on file:

Personal Alternate Contact Information: Name: Telephone: Address (P.O. Box not acceptable): Email:

14. Ownership Attestation:

A. Has any owner been directly or indirectly employed or affiliated with any school which has lost or been denied accreditation by any accrediting organization during that Y individual’s period of employment or affiliation? es No 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 owner been directly or indirectly employed or affiliated with any school that has closed 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 Y individual’s period of employment or affiliation? es No 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 owner been directly or indirectly employed or affiliated with any school that has lost or been denied eligibility to participate in Federal Student Financial Aid programs, Y including those under Title IV of the Higher Education Act? es No

OWNERSHIP/CONTROL DISCLOSURE FORM Revised 2016 (7/7/16) 3 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 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 Y any owner? es No 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 owner served in a similar capacity in any other school where either that individual or the school has been charged or indicted in a civil or criminal forum or proceeding Y alleging fraud, misappropriation, or any criminal act? es No 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 [Original] Signature:

Name (Typed)

Title Date

OWNERSHIP/CONTROL DISCLOSURE FORM Revised 2016 (7/7/16) 4