BLS-Green Form 326 Green Form 326199

Green Goods and Services Survey

O.M.B. No. 1220−xxxx

Expires Month Day Year

Please return this form within 14 days. If you need help completing this form, contact information is listed on the last page. Thank you!

West Dakota

012345678

Please report for location(s) in Using Unemployment Insurance account number

1

What is the address where your business is physically located?

Report data for the location below. If this address is no longer correct, please provide us with an updated address in the space provided.

Enter Physical Location Address Corrections Here

XYZ ADVISORS

4TH FLOOR

1310 SILVER STREET

SOMECITY WD 12345-6789

H

2

ave we identified your main business activity correctly?

We have listed below a description of your main business activity at this location. If this description is incorrect, please call XXX-XXX-XXXX or email [email protected].

NAICS code: 326199 All other plastics product manufacturing
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily engaged in: Manufacturing plastics products		Assembling plastics components into plumbing fixtures fittings such as faucets Foam (except polystyrene) products Heavy-duty inflatable plastics boats Laminating plastics profile shapes, such as plate, sheet, and rod Plastics bottles Plastics film, plastics unlaminated sheet, and plastics bags Plastics furniture parts and components Plastics pipes, pipe fittings, and plastics profile shapes (except film, sheet, bags) Plastics plumbing fixtures Polystyrene foam products Resilient floor coverings

W

3

hat is your business’s fiscal year?

Please provide us with your fiscal year that includes the month of June 2010.

Start of Fiscal Year				End of Fiscal Year
MM	DD	YYYY		MM	DD	YYYY

4

What is your percent revenue from specific product lines?

In Columns 1 and 3, please estimate the percent of total revenue for your location listed in Item 1 that comes from products containing more than 50% recycled or spent plastic resins. Please base your estimate on total revenue for your fiscal year from Item 3. The sum of Columns 1 and 3 may not equal 100%.

Note: This section may best be completed by someone at your firm with access to financial data.

Percent of Revenue for Fiscal Year listed in Item 3

1 Percent of total revenue for products with greater than 50% recycled or spent resins	2 Product line		3 Percent of total revenue for products with greater than 50% recycled or spent resins	4 Product line
	Awnings, rigid plastics or fiberglass, manufacturing			Lamp shades, plastics, manufacturing
	Badges, plastics, manufacturing			Lens blanks, plastics ophthalmic or optical, manufacturing
	Balloons, plastics, manufacturing			Mattresses, air, plastics, manufacturing
	Bathroom and toilet accessories, plastics, manufacturing			Microwaveware, plastics, manufacturing
	Bolts, nuts, and rivets, plastics, manufacturing			Motor vehicle moldings and extrusions, plastics, manufacturing
	Bottle caps and lids, plastics, manufacturing			Netting, plastics, manufacturing
	Bowls and bowl covers, plastics, manufacturing			Nozzles, aerosol spray, plastics, manufacturing
	Bubble packaging materials, plastics, manufacturing			Organizers for closets, drawers, and shelves, plastics, manufacturing
	Building materials (e.g., fascia, panels, siding, soffit), plastics, manufacturing			Packaging, plastics (e.g., blister, bubble), manufacturing
	Building panels, corrugated and flat, plastics, manufacturing			Pails, plastics, manufacturing
	Bushings, plastics, manufacturing			Paint sticks, plastics, manufacturing
	Cigar and cigarette holders, plastics, manufacturing			Picnic jugs, plastics (except foam), manufacturing
	Clothes hangers, plastics, manufacturing			Radio housings, plastics, manufacturing
	Clothespins, plastics, manufacturing			Reels, plastics, manufacturing
	Combs, plastics, manufacturing			Reflectors, plastics, manufacturing
	Coolers or ice chests, plastics (except foam), manufacturing			Rulers, plastics, manufacturing
	Countertops, plastics, manufacturing			Screening, window, plastics, manufacturing
	Credit and identification card stock, plastics, manufacturing			Septic tanks, plastics or fiberglass, manufacturing
	Cultured marble products (except plumbing fixtures) manufacturing			Shoe parts (e.g., heels, soles), plastics, manufacturing
	Cultured stone products (except plumbing fixtures) manufacturing			Shutters, plastics, manufacturing
	Cups, plastics (except foam), manufacturing			Siding, plastics, manufacturing
	Dinnerware, plastics (except polystyrene foam), manufacturing			Sponges, plastics, manufacturing
	Doormats, plastics, manufacturing			Swimming pool covers and liners, plastics, manufacturing
	Doors and door frames, plastics, manufacturing			Swimming pools, fiberglass, manufacturing
	Drums, plastics (i.e., containers), manufacturing			Tanks, storage, plastics or fiberglass, manufacturing
	Footwear parts (e.g., heels, soles), plastics, manufacturing			Television housings, plastics, manufacturing
	Fruits and vegetables, artificial, plastics, manufacturing			Tires, plastics, manufacturing
	Gloves, plastics, manufacturing			Trash containers, plastics, manufacturing
	Gutters and down spouts, plastics, manufacturing			Tumblers, plastics, manufacturing
	Hampers, laundry, plastics, manufacturing			Utility containers (e.g., baskets, bins, boxes, buckets, dishpans, pails), plastics (except foam), manufacturing
	Handles (e.g., brush, tool, umbrella), plastics, manufacturing			Watch crystals, plastics, manufacturing
	Hardware, plastics, manufacturing			Watering cans, plastics, manufacturing
	Ice buckets, plastics (except foam), manufacturing			Window sashes, vinyl, manufacturing
	Jars, plastics, manufacturing			Windows and window frames, plastics, manufacturing
	Kitchen utensils, plastics, manufacturing			Windows and window frames, vinyl, manufacturing
	Ladders, fiberglass, manufacturing			Windshields, plastics, manufacturing
	Other			Other
	Other			Other

W

5

hat is your contact information? For the person or persons who helped complete this form.

1. Contact 1’s name: __________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:__________________________________

Business website:______________________________________________

2. Contact 2’s name: ____________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:________________________________

D

6

o you have any questions about completing this form?

Please send an email to [email protected], or call (202)-691-XXXX.

Confidentiality Statement. The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. This report is authorized by law 29 U.S.C.2. Paperwork Reduction Act Statement. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate, and timely. We estimate that completing this form will take an average of 20 minutes. This estimate takes into account time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding this survey, including suggestions for reducing the burden, send them to the Bureau of Labor Statistics, Office of Industry Employment Statistics, Paperwork Reduction Project, 2 Massachusetts Avenue, N.E., Room 4840, Washington, DC 20212. The OMB control number for this voluntary survey is 1220-NEW and expires on month day, year. Without a currently valid number BLS would not be able to conduct this survey.

Please continue to the next page 1