Domestic Business Service Provider Registration Form

OMB Control No.: 0625-0237
Expiration Date: 04/30/2012

Domestic Business Service Provider (BSP) Registration

[Text may vary]

Please complete this form to indicate your interest in participating in the Commercial Service’s Business Service Provider Program. A Trade Specialist will review your registration and contact you. Please note that the fee for each Business Service Provider Category is X [fee will vary depending upon market]

Fields marked with * are required. ______________________________________________________________________________

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Contact & Company Information

Company Name*

First Name*

Last Name*

Salutation 

Title 

Company Address*

City*

State*

Zip Code*

Phone 

Fax 

Email*

Web Site 

Select your industry

Number of employees*

Select an Employee Range

______________________________________________________________________________

Business Service Providers

Please enter your company's point of contact information, if different from above, and company description in the following fields as you would like the information posted on our on-line Business Service Provider directory(s).

Contact Name

Contact Title

Contact Phone

Contact Fax

Contact E-mail Address

Company Address 

If different than the address provided above.

Short Business Service Provider Description*

Please try to provide a short description less than 75 characters.

Complete Business Service Provider Description*

Describe your company and the service you provide in 500 characters or less. This description may be edited for length and clarity. Please e-mail an electronic copy of your logo as a.jpg or .gif document (save as web file) with a width of exactly 200 pixels and height of up to 200 pixels to your Commercial Service contact.

Business Service Provider Categories*

I agree to pay for each category I choose. (Hold Ctrl-Key to select more than one):

[Note: Use existing dropdown box with category options]

____________________________________________________________________________

A

* Listings vary by region

dditional Business Service Provider Listings

A

Business Service Provider listing in a Pacific Northwest directory is $250. We can list you in additional directories in the Pacific Northwest region for $75 per listing.

Alaska	Oregon
Idaho	Spokane
Montana

_

_____________________________________________________________________________

How did you learn about this program?*

__________________________________________________________________________

Submission of business or personal information is voluntary. Please be aware of our Privacy Policy.

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Public reporting for this collection of information is estimated to be 5 minutes per response, including the time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection of information are voluntary, and will be provided confidentially to the extent allowed by law. Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Clearance Officer, International Trade Administration, Department of Commerce, Room 4001, 14th and Constitution Avenue, N.W., Washington, D.C. 20230.