Form NCUA 1772 NCUA 1772 NCUA Vendor Registration Form (VRF)

NCUA VENDOR REGISTRATION FORM, NCUA 1772
Company Information
Company Legal Name
Dun & Bradstreet No. (DUNS)
Registered in CCR / SAM?

1

Yes

No

Company Address
Company City, State and Zip
Company Phone Number
Company Fax Number
Website URL

Company Industry Information
Primary Industry Code (NAICS)2
Primary Supplies / Services Offered

Contact Information
Contact Person Name
Contact Person Title
Contact Phone Number
Contact Person Email Address

Legal Entity Type (Check one)
Individual / Sole Proprietorship

Business Classification (Check all that apply)
Minority-Owned4

Non-Minority
3

Partnership
Subchapter S Corporation
Subchapter C Corporation
Limited Liability Corp (LLC)

Small Business
Woman-Owned
Veteran-Owned
Service Disabled Veteran Owned

African American
Hispanic American
Asian-Pacific American
Native American

Non-Profit
Foreign Corporation

HUBZone
8(a)

Asian-Indian American5
Other (please explain)

Comments:

OMB 3133-0185
Footnotes:

SUBMIT

Expiration Date: 05/31/2013

1

The Central Contractor Registration website (federal government contractors' registration website) has been updated and relabeled

2

North American Industry Classification System - For your NAICS, enter keyword at http://www.census.gov/eos/www/naics/

3

A firm is a small business if its average 3-year revenue falls below the revenue size standard for its primary industry code.

under the System for Awards Management (SAM) at www.SAM.gov.

4

A firm is minority-owned, woman-owned, or veteran / service disabled-owned, if it is at least 51% owned and controlled by
one or more individuals that are themselves minorities, women or veterans / service disabled veterans, respectively.
5
As ian - I ndi an : a U.S . citizen whose origins are from I ndia, Pakista n or Bangladesh.
6 The NCUA may not collect this information, and you are not required to complete this form unless it displays a currently valid control
number. Estimated time to complete this form is 10 minutes.