BAS-6 BAS 6 - Consolidated BAS

FORM

U.S. DEPARTMENT OF COMMERCE

BAS-6

U.S. CENSUS BUREAU

CONSOLIDATED BAS (CBAS) AGREEMENT FORM
To sign up for the Consolidated BAS (CBAS) program, please complete this form.
1.) Reach out to the BAS Contacts for the entities in your county's jurisdiction. Email to request BAS Contact information.
2.) Complete the Participation Roster below as you communicate with the BAS Contacts for the entities in your county's jurisdiction.
3.) Return the completed CBAS Form by email to

GENERAL
INSTRUCTIONS

Name of county, parish, borough or equivalent area

State

STATE CODE

BAS ID
Section 1

Economics and Statistics Administration

BOUNDARY AND ANNEXATION SURVEY (BAS)

OMB Control No. 0607-0151
Expiration Date: XX-XX-XXXX

COUNTY CODE

CBAS CONTACT MAILING ADDRESS (Address where Consolidated BAS materials should be sent) – Please fill in contact information below.

Name:

Address:

Position:
Department:

City:

Telephone:

(

)

–

Fax:

(

)

–

Ext:

ZIP code

State:
E-mail:

Instructions for filling out this form:
1.) Enter the Entity Name, including the type of entity, such as "city", "town", "township" for the government entities in your jurisdiction.
2.) Enter a Y (Yes) or N (No) in the "Agreed" column to note each contact’s response to participating in the CBAS program.
3.) Fill in the name, position, and phone number of the contact person you spoke with from each entity. Please provide this information for all entities in your jurisdiction.
4.) Enter the date that you spoke with each entity contact in the "Date of Contact" column.
Section 2
BAS ID

PARTICIPATION ROSTER
Entity Name

Agreed?
Y/N

Contact Name

Position

Telephone Number

Date of
Contact

For further information, please contact the BAS team by phone at (301) 763-1099 or by email at [email protected]. Please reference "CBAS" in the subject of your email.

Section 2
BAS ID

FORM BAS-6 (10-12-2011)

PARTICIPATION ROSTER – Continued
Entity Name

Agreed?
Y/N

Contact Name

Position

Telephone Number

Date of
Contact

Section 2
BAS ID

PARTICIPATION ROSTER – Continued
Entity Name

Agreed?
Y/N

Contact Name

Position

Telephone Number

Date of
Contact

FORM BAS-6 (10-12-2011)

We estimate that completing this form will take 30 minutes on average. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
[email protected]. This collection has been approved by the Office of Management and Budget (OMB). The eight digit OMB approval number that appears at the upper left of the form confirms this approval. If this number
were not displayed, we could not conduct this survey. The Census Bureau conducts this program under the legal authority of the Title 13 U.S. Code, Section 6.