Customer Profile Form printable pdf download

CUSTOMER PROFILE FORM

The purpose of this form is to provide customer and contact information for those customers and contacts which need

to be established in the Bureau of Industry and Security (BIS) and National Oceanic and Atmospheric Administration

(NOAA) customer database in the Core Financial System. NOAA will use the information only for the purposes

stated in the references cited above and will restrict access to the data to authorized personnel who will use it only for

the specified purposes. If the customer is an individual (Consumer) complete the italic fields only unless otherwise

noted.

Please check one: ____ NEW ____ CHANGE (please complete customer name and only those areas which have

changed)

NAME: Legal Name__________________________________________

Division/subunit______________________________________(Not applicable to Consumers)

Acronym or shortened name_____________________________ (6 characters/digits or less)

Type of Customer (select one):

_____BIS Employee

_____Foreign Commercial

_____NOAA Employee

_____Foreign Government

Consumer

_____Joint/Multiple Debtors (Civil Monetary Penalties)

_____

_____Commercial

_____State/Local Government

_____Federal Government

_____University

Agency Location Code ____________________(For Federal Government Agencies only)

Bill through IPAC? (Check one) ’ Yes

’ No

Taxpayer Identification Number (TIN)

SSN (individual/sole proprietorship)

_____

_____ _____ _____ -_____ _____ -_____ _____ _____

EIN (Corporation/partnership/sole proprietorship with one or more employees)

_____ _____ - _____ _____ _____ _____ _____ _____ _____

Parent Company Name

________________________________________________________________

Parent Company EIN _____ _____ - _____ _____ _____ _____ _____ _____ _____

Please provide a Customer Name and billing contact address below. (Applies to all Customer Types):

*Customer Name____________________________________________________

*Contact Name and/or Title ___________________________________________

*Address line 1_____________________________________________________

Address line 2_____________________________________________________

*City_____________________________________________________________

*State_________________*ZIP_________________*Country_______________

*DUNS Number _____ _____ _____ _____ _____ _____ _____ _____ _____

Phone__________________________ Fax________________________

Internet E-mail address______________________________________________

*Required

Customer Profile Form

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