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NCUA VENDOR REGISTRATION FORM NCUA 1772 Company Information Company Legal Name Dun Bradstreet No. DUNS Registered in CCR / SAM 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 Phone Number Legal Entity Type Check one Individual / Sole Proprietorship Business Classification Check all that apply Minority-Owned4 Non-Minority Partnership Subchapter S 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 The Central Contractor Registration website federal government contractors registration website has been updated and relabeled North American Industry Classification System - For your NAICS enter keyword at http //www. census. gov/eos/www/naics/ 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* 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. 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. census. gov/eos/www/naics/ 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* 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. under the System for Awards Management SAM at www. SAM. gov* 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. 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. census. gov/eos/www/naics/ 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* 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. 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.