Form NCUA 1772 NCUA 1772 NCUA Vendor Registration Form

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NCUA VENDOR REGISTRATION FORM, NCUA 1772
* Indicates a required field

Company Information
Company Legal Name
Dun & Bradstreet No. (DUNS)
Registered in SAM?1
Company Address

Yes

No

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

Click here to insert a hyperlink

'http://' is required to be included in the hyperlink entered above

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

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

Legal Entity Type (Select one)

Business Classification (Check all that apply)

Individual / Sole Proprietorship

Small Business3

Woman-Owned

Select...

ఔ

Partnership

Veteran-Owned

Minority-Owned4

Select...

ఔ

Subchapter S Corporation

Service Disabled Veteran Owned

Subchapter C Corporation

HUBZone

Limited Liability Corp (LLC)

8(a)

Non-Profit/Government Institution
Foreign Corporation
Comments:
Please use this section to enter keywords and/or provide additional information about your business.

Submit
OMB 3133-0185

http://devforms.ncua.lan/Pages/VendorRegForm.aspx

3/9/2016

Pages - Vendor Registration Form

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Footnotes:
1

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

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.

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

Asian-Indian: a U.S. citizen whose origins are from India, Pakistan or Bangladesh.

NOTE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The time required to complete this information collection is estimated to average 10 minutes per response, including
the time to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. If you have comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, send comments to: NCUA OCIO/PRA, National Credit Union Administration, 1775 Duke Street, Alexandria,
Virginia 22314.

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3/9/2016