BLS-Green Form 541 Green Form 541380

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: 541380 Testing laboratories
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily engaged in: Assaying Biological testing (except medical and veterinary) Calibration testing Electrical and electronic testing Geotechnical testing Mechanical testing The testing may occur in a laboratory or on-site.	Non-destructive testing, or thermal testing Performing physical, chemical, and other analytical testing services, such as acoustics or vibration testing	Auto emissions testing Laboratory testing for the medical profession Veterinary testing services

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 business activities?

In Columns 1 and 3, please estimate the percent of total revenue for your location listed in Item 1 that comes from the activities listed below. Please base your estimate on total revenue for your fiscal year from Item 3. The sum of Columns 1 and 3 should 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	2 Business activities		3 Percent of total revenue	4 Business activities
	Acoustics testing laboratories or services			Pollution testing (except automotive emissions testing) services
	Assaying services			Product testing laboratories or services
	Automobile proving and testing grounds			Radiation dosimetry (i.e., radiation testing) laboratories or services
	Biological (except medical, veterinary) testing laboratories or services			Radiation testing laboratories or services
	Calibration and certification testing laboratories or services			Radiographic testing laboratories or services
	Electrical testing laboratories or services			Radiographing welded joints on pipes and fittings
	Electronic testing laboratories or services			Radiography inspection services
	Environmental testing laboratories or services			Radon testing laboratories or services
	Film badge testing (i.e., radiation testing) laboratories or services			Seed testing laboratories or services
	Fire insurance underwriters' laboratories			Soil testing laboratories or services
	Food testing laboratories or services			Testing laboratories (except medical, veterinary)
	Forensic (except medical) laboratories or services			Thermal testing laboratories or services
	Geotechnical testing laboratories or services			Vibration testing laboratories or services
	Hydrostatic testing laboratories or services			X-ray inspection services
	Industrial testing laboratories or services			Other
	Laboratory testing (except medical, veterinary) services			Other
	Mechanical testing laboratories or services			Other
	Metallurgical testing laboratories or services			Other
	Non-destructive testing laboratories or services			Other

W

5

hat is your contact information? for 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 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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