BLS-Green Form 334 Green Form 334513

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

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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: 334513 Instruments and related products manufacturing for measuring, displaying and controlling industrial process variables
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily engaged in manufacturing: Instruments and related devices for measuring, displaying, indicating, recording, transmitting, and controlling industrial process variables These processes may include: Temperature, humidity, pressure, vacuum, combustion, flow, level, viscosity, density, acidity, concentration, and rotation		Glass hydrometers and thermometers for other nonmedical uses Instruments and instrumentation systems for laboratory analysis of samples Instruments for measuring or testing of electricity and electrical signals Medical thermometers Optical alignment and display instruments, optical comparators, and optical test and inspection equipment

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 activities?

In Column 1, please estimate the percent of total revenue that comes from the categories of green activity shown in the table below for your location listed in Item 1. Please base your estimate on total revenue for your fiscal year from Item 3. The sum of Column 1 should be 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 your fiscal year	2 Green activity
	Renewable energy: research on and development, production, storage, and distribution of energy from renewable sources
	Energy efficiency: research on and development and implementation of energy conservation technologies and practices
	Greenhouse gas reduction: research on and development and implementation of technologies and practices to reduce greenhouse gas emissions through approaches other than renewable energy generation and conservation
	Pollution reduction and clean-up: research on and development and implementation of technologies and practices to reduce the emission of pollutants and remove pollutants and hazardous waste from the environment
	Recycling and waste reduction: research on and development and implementation of technologies and practices to collect and recycle materials and waste water
	Other
	Other

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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:________________________________

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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.

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