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PLEASE TYPE INFORMATION FORM BC-1868 EF 11-9-2010 U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration U.S. CENSUS BUREAU REQUEST FOR OFFICIAL CERTIFICATION Section I CONTACT INFORMATION Complete items 1 5 1. Today s date 2. Date needed 3. Contact a* Name b. Company c* Address 1 d. Address 2 e. City f* State g. ZIP Code h. Telephone number i. Fax number j. E-mail address 4. Detailed explanation of your certification request List exact tables or furnish examples etc* if possible If more space is needed use a blank page to continue and be sure to put your name at the top* 5. Where to send this request If you have any questions please phone 1 800 923 8282. E-mail to Clmso. Certify. List census. gov Attach form Fax to Customer Services Center/CLMSO 301-763-3842 Section II FOR INTERNAL USE ONLY Do NOT write below this line Line 1 Line 2 Line 3 Line 4 Tracking number Date received Division assigned Name Code Comments Price Date customer returned approval Customer approval Yes No Order number Line 5 Date order entered Line 6 DIV to CQAS date Line 7 CQAS to CLMSO date CQAS tracking code Line 8 Date product sent to customer FedEx tracking code Date sent to division. Today s date 2. Date needed 3. Contact a* Name b. Company c* Address 1 d. Address 2 e. City f* State g. ZIP Code h. Telephone number i. Fax number j. E-mail address 4. Detailed explanation of your certification request List exact tables or furnish examples etc* if possible If more space is needed use a blank page to continue and be sure to put your name at the top* 5. ZIP Code h. Telephone number i. Fax number j. E-mail address 4. Detailed explanation of your certification request List exact tables or furnish examples etc* if possible If more space is needed use a blank page to continue and be sure to put your name at the top* 5. Where to send this request If you have any questions please phone 1 800 923 8282. E-mail to Clmso. Certify. Where to send this request If you have any questions please phone 1 800 923 8282. E-mail to Clmso. Certify. List census. gov Attach form Fax to Customer Services Center/CLMSO 301-763-3842 Section II FOR INTERNAL USE ONLY Do NOT write below this line Line 1 Line 2 Line 3 Line 4 Tracking number Date received Division assigned Name Code Comments Price Date customer returned approval Customer approval Yes No Order number Line 5 Date order entered Line 6 DIV to CQAS date Line 7 CQAS to CLMSO date CQAS tracking code Line 8 Date product sent to customer FedEx tracking code Date sent to division. Today s date 2. Date needed 3. Contact a* Name b. Company c* Address 1 d. Address 2 e. City f* State g. ZIP Code h. Telephone number i. Fax number j. E-mail address 4. Detailed explanation of your certification request List exact tables or furnish examples etc* if possible If more space is needed use a blank page to continue and be sure to put your name at the top* 5. Where to send this request If you have any questions please phone 1 800 923 8282. E-mail to Clmso. Certify.

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