Vendor Survey Form.doc
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- LCNLS08R0169
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Library of Congress
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Vendor Survey Form
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Text version
Library of Congress Vendor Information Request
CEC / DUNS Number + Four
Please Fax to Office of Contracts and Grants Management
| (202) 707-8611 or LOC Office: |
| SSN / TIN |
| FORMCHECKBOX |
Corporations of partnerships use Federal Taxpayer Identification Number (TIN)
FORMCHECKBOX
Independent contractors or sole proprietors use Social Security Number (SSN)
FORMCHECKBOX
Foreign firms without TIN, do not enter number.
VENDOR TYPE
FORMCHECKBOX
| 1. Employee |
| FORMCHECKBOX |
| 2. Federal |
| FORMCHECKBOX |
3. Nonfederal
TYPE OF BUSINESS
FORMCHECKBOX
| 1. Small Disadvantaged Business |
| FORMCHECKBOX |
| 7. Other Nonprofit Organization |
| FORMCHECKBOX |
13. Federal Government – Within Bureau
FORMCHECKBOX
| 2. Other Small Business |
| FORMCHECKBOX |
| 8. State/Local Government Education |
| FORMCHECKBOX |
14. Foreign Contractor
FORMCHECKBOX
| 3. Large Business |
| FORMCHECKBOX |
| 9. State/Local Government Hospital |
| FORMCHECKBOX |
15. Domestic Contractor
FORMCHECKBOX
| 4. Sheltered Workshop |
| FORMCHECKBOX |
| 10. Other State/Local Government |
| FORMCHECKBOX |
16. Woman Owned Business
FORMCHECKBOX
| 5. Nonprofit Educational Organization |
| FORMCHECKBOX |
| 11. Federal Government – Non Dept. |
| FORMCHECKBOX |
17. Minority Owned Business
FORMCHECKBOX
| 6. Nonprofit Hospital |
| FORMCHECKBOX |
| 12. Federal Government – Within Dept. |
| FORMCHECKBOX |
18. Emerging Small Business
| NAME OF BUSINESS OR INDIVIUAL |
| ALTERNATE NAME / DOING BUSINESS AS |
| PRIMARY CONTACT NAME |
| TELEPHONE NUMBER |
| E-MAIL ADDRESS |
| FINANCIAL CONTACT NAME |
| TELEPHONE NUMBER |
| E-MAIL ADDRESS |
| SIC CODE |
| PRIMARY BUSINESS PRODUCT |
MAILING ADDRESS
ADDRESS LINE 1 (P.O. Box, or Number and Street)
ADDRESS LINE 2 (Building, Suite, etc.)
| CITY |
| STATE |
| ZIP CODE |
| COUNTRY |
FORMTEXT
| TELEPHONE NUMBER |
| FAX NUMBER |
REMITTANCE ADDRESS (Complete only if different than the address above)
ADDRESS LINE 1 (P.O. Box, or Number and Street)
ADDRESS LINE 2 (Building, Suite, etc.)
| CITY |
| STATE |
| ZIP CODE |
| COUNTRY |
FORMTEXT
| TELEPHONE NUMBER |
| FAX NUMBER |
ACH FINANCIAL INSTITUTION INFORMATION
| FINANCIAL INSTITUTION NAME |
| ROUTING / ABA NUMBER |
| ACCOUNT NUMBER |
| TYPE |
| FORMCHECKBOX |
Corporate Checking
FORMCHECKBOX
Lockbox
FORMCHECKBOX
Personal Checking
FORMCHECKBOX
Savings
| CITY |
| STATE |
| ZIP CODE |
| COUNTRY |
FORMTEXT
ACCOUNT TITLE (if different than name of business or individual)
CERTIFICATION OF INFORMATION
I understand that the Library of Congress will make payments by ACH and have provided ACH financial institution information.
| NAME |
| TITLE/POSITION |
| TELEPHONE NUMBER |
| SIGNATURE |
| DATE |
FOR LICENSING DIVISION USE ONLY
| LEGAL NAME (AS ON STATEMENT OF ACCOUNT) |
| ID# |
| PERIOD |
| TYPE |
The Library of Congress maintains a website which provides information regarding the status of vendor invoices, invoice payments, and other transactions at: http://lcweb.loc.gov/fsd OPM Form 1616—ES-version
OGC approved on: 10/27/99 MOMENTUM – Revised Form 184 (2004/08)
File details come from the government source that posted it. Updated .