DERCO BUSINESS STATUS SURVEY

	Vendor Registration and Business Size Information All fields must be completed in order to submit this form unless otherwise noted.

SECTION A: GENERAL BUSINESS INFORMATION
Legal Business Name:
Business Street Address:
	CAGE Code:

City:

State:

Zip Code:

Business Contact Info:	Name:	Phone Number:
	E-mail:	Fax Number:
	Web URL:

SECTION B: VENDOR MAILING ADDRESS
Mailing Address: (Complete if different from business address)

City:

State:

Zip Code:

SECTION C: VENDOR REMITTANCE ADDRESS & ACCOUNTS RECEIVABLE INFORMATION
Remittance Address: (Complete if different from above.)

City:

State:

Zip Code:

Accounts Receivable Contact Info:	Name:		Phone Number:
	E-mail:		Fax Number:

SECTION D: BUSINESS INFORMATION

Business Type:

Manufacturer

Distributor

FAA Repair

Other

	List Principal Products and Services:

Tax ID Number:

Tax ID/Status:

Corporation

Partnership

Sole Proprietor

Dun & Bradstreet No:

NAICS Code(s):

NAICS Code Search:

http://www.census.gov/epcd/www/naicstab.htm

ITAR Compliance:
Do you supply or manufacture ITAR controlled items?	Yes	No
If yes, are you registered with the DDTC to supply or manufacture ITAR controlled items?	Yes	No
If yes, please provide DDTC registration expiration date:

SECTION E: BUSINESS STATUS (SELECT ALL THAT APPLY)

SMALL BUSINESS

LARGE BUSINESS

GOVERNMENT AGENCY

	Disadvantaged		BLACK COLLEGE OR UNIVERSITY
	Women-Owned		MINORITY INSTITUTION
	Veteran-Owned
	Disabled Veteran-Owned
	Alaska Native Corporations (ANC) and Indian Tribes-not identified by the SBA as a small disadvantaged business
	Alaska Native Corporations (ANC) and Indian Tribes-that are not a small business
	HUBZone

Completed by:

Date:

(Signature if sending hard copy. Otherwise, Typed name in Signature Block is considered electronic signature verifying data is correct)

Printed Name:

Title:

Please submit a completed form to Derco Aerospace, Inc. on-line following the provided instructions or mail completed form to: Derco Aerospace, Inc., Attn: SBLO, 8000 West Tower Avenue, Milwaukee, WI 53223 Or FAX this completed form to (414) 214-2268 - Attn: SBLO. Please call (414) 371-3333 with any questions.