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Small Business
Registration Form

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Contact Information

Company Name:

Address:

   

Contact Person Info:
Name:
Phone Number:
E-mail:
Website:

Company Information

Type Of Small Business (mark all that apply)
   Native American  Veteran Owned
     Disadvantaged Business  8(a) certified
   Woman-Owned Business  HUBZone certified
   Service-Disabled Veteran Owned  Other   
 
On Federal Schedule?
     No        Yes - Contract Number
 
Note: The PSC Codes and NAICS codes listed in the drop-down menus below reflect the services the Census Bureau most often requires. If there is a code for a service that your company provides that is NOT listed, and you think it could benefit the Census Bureau, please list it in the "Brief Capabilities Statement" section at the bottom.
 
Product/Service Classification (PSC) Codes  (Hold down the "Ctrl" button for multiple selections.)
 
  Product/Service Classification (PSC) Codes
 
NAICS Code(s)  (Hold down the "Ctrl" button for multiple selections.)
 
  NAICS Codes
 

Brief Capabilities Statement (Limit 2000 characters)
  Please include 3-5 past performance contracts you have worked on successfully for other
  government agencies or private industry.


          Please do not include your Social Security Number or other sensistive pesonal information in the box below.

characters left


Privacy Act Statement

The collection of your personal information for the Small Business Registration form is authorized under 44 U.S.C. Section 3101.

The purpose of collecting this information is to assist the Census Bureau in researching the products or services companies may be able to provide to the Census Bureau. Personally identifiable information such as your name, email address, phone number, company name and address may be collected in order to fulfill this need.

Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be shared among Census Bureau staff for work-related purposes. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act system of Records Notices COMMERCE/Dept-19, Mailing Lists.

Providing this information is voluntary. Failure to provide this information may affect the Census Bureau's ability to conduct accurate research into the products or services companies can provide, and may affect your ability to be included in the Census Bureau's market research phase when searching for products or services.



Source: U.S. Census Bureau
Acquisition Division

Last Revised: June 16, 2014