Vendor Outreach Registration Form

-- Privacy Notice -NOTE:
Please complete all mandatory items on this form.
Mandatory items are marked with an asterisk (*).
Click on relevant links for additional help.

User Name:
Password:
* Company Name:
* Contact Name:

Mr

* Address:

* City:
* State:

DC

* Zip:
* E-mail Address:
* Phone Number
(format: xxx-xxx-xxxx):
Fax Number:
Web site URL:
Small Business Categories - Check all that
apply.
Small Business
Small Disadvantaged Business - SBA
Certificate
8 (a) - SBA Certified
HUBZone - SBA Certified
Women-Owned
Veteran-Owned
Service-Disabled Veteran-Owned
Services/Products:
(Use control-click to select multiple
services/products.)
GSA Schedule Number(s):

Administrative Support Services

* NAICS Codes:

On PRO-Net:
PRO-Net URL:
Accept Government Purchase Cards?
Interested in Job Corps work? Check all that
apply.
Center Operations
Outreach and Admission
Technical Assistance and Support Services
Architectural, Engineering, and Construction
CERTIFICATION - I certify that information supplied herein is correct and that neither the applicant nor any person (or concern) in any connection
with the applicant as a principal or officer, so far as is known, is now debarred or otherwise declared ineligible by any agency of the Federal
government from making offers for furnishing materials, supplies, or services to the government or any agency thereof.

The data is being collected under OMB clearance number 1290-0002 (expiration date 5/31/2011). Without this currently approved number, we could
not collect the data.
Persons are not required to respond to a collection of information unless it displays a currently valid OMB control number. We estimate it will take
approximately seven minutes to register initially for the Small Business Information System and two minutes to login and update the data. By
providing this data, you will help OSDBU maintain accurate and useful information on your organization. Your provision of the requested data is
completely voluntary.
Please send comments regarding the burden estimate, included suggestions for reducing the burden to Isela Martin at [email protected].

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