D-1746 Registration Form

OMB No. 0607-0795 (expires April 30, 2012)

D-1746

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

FORM
(6-29-2009)

Registration Form: 2010 Census
New Construction Program
Please complete this form and return it to your
U.S. Census Bureau Regional Office

Entity ID Code (Overprint)

Entity Name (Overprint)

A. Participation Information
1.

YES! Our government would like to participate in the New Construction program.
Select One Map Type For Reference Only:
Reference Shapefile on CD-ROM (including an MTPS program disc for users without GIS software)
OR
Reference PDF Maps on CD-ROM

2.

NO, we are not able to participate. Please select all that apply below. We rely on your comments to
help us improve the New Construction program.

a.

Insufficient staff

e.

Unable to provide electronic submission

b.

Lack of funds

f.

No new addresses

c.

No time/too busy

g.

Other reason:

d.

No local address list available
B. Official Making this Commitment (Please print)

Name (first, middle initial, last)
Signature of official (first, middle initial, last)
Position (Commissioner, Mayor, Supervisor, etc.)
Telephone Number

E-mail Address

Date (mm/dd/yy)

C. Liaison Information
Please designate your official 2010 New Construction program liaison (work contact) by providing
the following information. (Please print)
Name (Please Print first, middle initial, last)
Position (Please Print Director, Assessor, Planner, etc.)
Department, Organization, or Agency Name
Mailing Address
City

State

ZIP code

Delivery Address (House number and street name, the Census Bureau will ship all materials via FedEx. Fedex will not deliver to
P.O. Box numbers or P.O. ZIP Codes.)
City

Telephone Number

USCENSUSBUREAU

State

Fax Number

ZIP code

E-mail Address