BLS-Green Form 238 Green Form 238212

Green Goods and Services Survey

O.M.B. No. 1220−0181

Expires September 30, 2010

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

Statename

UI (10 digits)

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

1

What is the address where your business establishment 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

T_name

Phy_addr2

Phy_addr1

Phy_city, Phy_state phy_zip-phy_zip_ext

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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 202-691-5185 or email [email protected].

NAICS code: 238212 Nonresidential Electrical Contractors and Other Wiring Installation Contractors
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily engaged in nonresidential: Installation and servicing of electrical wiring and equipment Work may include new work, additions, alterations, maintenance, and repairs		Installing and maintaining telecommunications lines by telecommunications companies Constructing power and communication transmission lines Burglar and fire alarm installation combined with sales, maintenance, or monitoring services

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3

hat is your business establishment’s fiscal year?

Please provide us with your fiscal year that includes April 15, 2009 for the location listed in Item 1.

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

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4

hat is your business establishment’s employment?

Please provide us with the employment figure you reported on your State’s Quarterly Contributions Report for September 2009 for the location listed in Item 1. This figure is the count of all employees subject to State Unemployment Insurance taxes that worked or received pay for the pay period that included September 12^th, 2009.

Employment for pay period that includes September 12, 2009

5

What is your percent revenue from specific business activities?

In Columns 1 and 3, please estimate the percent of total revenue at the location listed in Item 1 that comes from electrical and wiring jobs on EnergyStar or LEED (Leadership in Energy and Environmental Design) certified residential buildings or from weatherization or retrofitting projects that increase the energy efficiency of a residential building. 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 total revenue for fiscal year listed in Item 3
1 Percent of total revenue from EnergyStar, LEED certified or projects that increase energy efficiency	2 Business activities		3 Percent of total revenue from EnergyStar, LEED certified or projects that increase energy efficiency	4 Business activities
	Airport runway lighting contractors, nonresidential			Highway, street and bridge lighting and electrical signal installation, nonresidential
	Alarm system (e.g., fire, burglar), electric, installation only, nonresidential			Home automation system installation, nonresidential
	Audio equipment installation (except automotive) contractors, nonresidential			Home theater installation, nonresidential
	Building automation system installation contractors, nonresidential			Humidity control system installation, nonresidential
	Burglar alarm system, electric, installation only, nonresidential			Intercommunication (intercom) system installation, nonresidential
	Cable splicing, electrical or fiber optic, nonresidential			Lighting system installation, nonresidential
	Cable television hookup contractors, nonresidential			Low voltage electrical work, nonresidential
	Communication equipment installation, nonresidential			Private driveway or parking area lighting contractors, nonresidential
	Computer and network cable installation, nonresidential			Public address system installation, nonresidential
	Control system (e.g., environmental, humidity, temperature) installation, nonresidential			Railroad signalling equipment installation, nonresidential
	Electric contracting, nonresidential			Security and fire system, installation only, nonresidential
	Electric power control panel and outlet installation, nonresidential			Smoke detection system, installation only, nonresidential
	Electrical contractors, nonresidential			Snow melting cable, electric, installation, nonresidential
	Electrical equipment and appliance installation, nonresidential			Sound equipment installation, nonresidential
	Electrical wiring contractors, nonresidential			Surveillance system, installation only, nonresidential
	Electrical work, nonresidential			Telecommunications equipment and wiring (except transmission line) installation contractors, nonresidential
	Electrical, electrical wiring, and low voltage electrical work, nonresidential			Telephone equipment and building wiring installation, nonresidential
	Electrician, nonresidential			Telephone installation contractors, nonresidential
	Electronic containment fencing for pets, installation, nonresidential			Temperature control system installation, nonresidential
	Electronic control installation and service, nonresidential			Traffic signal installation, nonresidential
	Electronic control system installation, nonresidential			Tunnel lighting contractors, nonresidential
	Environmental control system installation, nonresidential			Other (please specify):
	Fiber optic cable (except transmission lines) installation, nonresidential			Other (please specify):
	Fire alarm system, electric, installation only, nonresidential			Other (please specify):

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6

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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7

o you have any questions about completing this form?

Please send an email to [email protected], or call (202)-691-5185.

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 1220-0181 and expires on September 30, 2010. Without a currently valid number BLS would not be able to conduct this survey.

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