Central Contractor Registration Form

Central Contractor Registration Form

Are you Registered with the Florida SBDC/PTAC? If not, please go to

(M) = Mandatory field. Data must be entered for registration to be complete.
You may have your local PTAC enter your information for you at their offices. Since they do many of these and correct any problems that might come up, it is in your business interest to have them assist you in filling out this registration.

Before you even start this application, you will need Duns (Dun and Bradstreet number). If you do not have, one you can call 866-705-5711 and get a FREE number.

Information Opt-Out

You may opt out from displaying your company information on the CCR Public Search page. This may result in a reduction in federal government business opportunities. Ok for those of you that think that you do not want your company information online where everyone will see it. Remember this, you are trying to get a contract with the Federal Government, if you hide yourself; I can almost guarantee that you will not be found. Yes, your going to get some spam, and some people that will have the most wonderful way for you to find and get government contracts $xxx.xx, (don’t you believe it). But remember, you get a lot of junk mail anyway, do what you do with it…throw it out! In addition, remember that this is the ONLY list that the government uses when it looks for contractors.
So, select one of the following options:

______I authorize my company information to be displayed in CCR's Public Search.

Please select an Opt-Out value.

______I DO NOT authorize my company information to be displayed in CCR's Public Search.
The first thing you will be doing is creating a “user account,” please follow the directions CAREFULLY, FILL OUT ALL THE INFORMATION. If you are going to have an “alternate person”, set them up at this time.

Marketing Partner ID (MPIN) (M) ______

You MUST create the MPIN which is 9 characters consisting of at least
1 number,
1 letter,
no spaces,
no symbols

MPIN is Mandatory .Marketing Partner ID (MPIN): This is your self-defined access code that will be shared with authorized partner applications (e.g., Past Performance Automated Information System (PPAIS), Technical Data Solutions (TeDS), etc.).

The MPIN acts as your password in these other systems, and you should guard it as such.

Creating a User Account,

To create a User Account you will need the following information.

A User ID which is your login signature, i.e. Jsmith, janejones123 etc. in this case we will use jjames, a login can be any numbers of characters is not case sensitive and does not need numbers or special characters like !@# or %.
Then you will create a password using the following:
It must be from eight to fifteen characters and have at least one upper case character, one lower case, one number, and one special character. Which will look a little like this: JohnSmith23# or janeJones1965@ or #ACMEcomp4.

Worksmart: At this time your password must change every 60 days. It must be different from the last 6 passwords and you cannot change it more often then 24 hours and if you forget it and you try to get in three times and miss…. you will be locked out for at least an hour. Therefore, I suggest you write it down in not just one place. I find the best way to keep track of things is to have two (2), three ring binders. One at the office and one at home, that way if you forget or lose the binder, and you will, you can call your spouse and ask them what your login and password is.

Creating Your User Account

Ok so now you need to create your User Account. You are going to need to get together the following information.

* User id ______(that’s what you created above)
Password ______
The following rules apply to CCR passwords:
* A password must contain at least eight total characters including at least one upper case, one lower case, one number, and one special character (i.e., @, #, $, %, *).
* An example of an acceptable password is AB123#$de.
* First name ______
* Last name ______
Address one ______
Address two ______
City ______
State ______
Zip ______Plus Four ______(you MUST have the Zip Plus Four Numbers. You can find that at
* Telephone number ______
Extension number, if needed. ______
FAX number ______
* Email address ______

* Only things that are required are 1,2,3, 9 and 12.

However, I would really suggest you put all the info in, it is just good practice.

Select and Answer

In what city did you meet your spouse/significant other? ______

In what city did your parents meet?______

What is the name of the first person you kissed?______

In what city did your nearest relative live in 2010? ______

In what city was your first job?______

What is the name of the college you applied to but did not attend? ______

Where were you when you first heard about 9/11?______

THIS IS A SAMPLE WHAT YOU WILL END UP WITH.

KEEP FOR YOUR RECORDS- Do Not Lose

l details.

CONSENT TO DISCLOSURE OF TAX INFORMATION
I hereby authorize the Internal Revenue Service (IRS) to validate that the Legal Business Name and Taxpayer Identification Number (TIN) (Employer Identification Number or Social Security Number) provided by the registrant matches or does not match the name and/or name control and TIN in the files of the IRS for the most current tax year reported.
Pursuant to 26 U.S.C. 6103(c), I hereby authorize the Internal Revenue Service (IRS) to disclose to the officers and employees of the Central Contractor Registration (CCR) Program Office whether the name and/or name control and TIN provided in connection with this registration is the TIN maintained in IRS files for the taxpayer name listed below for the most current tax year reported. I recognize that this validated TIN will reside on the CCR and be accessible to Federal Government procurement officials and other government personnel performing managerial review and oversight, for use in all governmental business activities including tax reporting requirements and debt collection.
I understand that without this consent a registrant's return information, including registrant's name and TIN, is confidential.
In addition by providing the following information, I certify that I have the authority to execute this consent for the disclosure of return information on behalf of the registrant.

Top of Form

Taxpayer Name: / ______
Taxpayer Identification Number (TIN): / ______(See Note Above for IRS Definition)
Taxpayer Street Address 1: / ______
Taxpayer Street Address 2: / ______
Taxpayer City: / ______
Taxpayer State: / ______
Taxpayer Zip+4/Postal Code: / ______+ ______
Taxpayer Country: / ______
Type of Tax: / ______
Tax Year (insert most recent tax year): / ______
Name of Individual Executing Consent: / ______
Title of Individual Executing Consent: / ______
Signature (enter your MPIN here): / ______
Date: / ______

Bottom of Form

You may have your local PTAC enter your information for you at their offices. Since they do many of these and correct any problems that might come up, it is in your business interest to have them assist you in filling out this registration.

Please select an Opt-Out value.

This is where your going to put in the General Information.
Remember that the (M) means MANDATORY, you must have the information in there.

DUNS Number1(M): CAGE Code2(M if foreign):
CAGE code will be assigned to you if you do not have one

Legal Business Name(M):

Doing Business as (DBA Name)

Tax ID/EIN 3(MIf in U.S):

OR (M)Social Security Number:

Division Name: Division Number:

Corporate Web Page URL (Company website address):

Example:____ or

WORK SMART. You have no idea how many companies I deal with that spend thousands and thousands of dollars on their website and don’t add their link in. Think about this…this is your way to link into your best advertising and marketing tool, your website. Don’t forget it.

Physical Address (M):

City (M):______State (M):______

Province (all countries other than USA or Canada)______

Zip/Postal Code (M):Zip Plus 4 (M)Country (M):______

Mailing Address (M): Check if same as physical address

Business Name (M):

Mailing Address (PO Box is acceptable) (M):

City (M):State (M):

Province (all countries other than USA or Canada)______

Zip/Postal Code (M):Zip Plus 4 (M)Country (M):______

Business Start Date (M) (mm/dd/yyyy):______

Fiscal Year Close Date (M) (mm/dd):______

The following information will be used to derive your small business size status based on SBA size standards.

Penalties for misrepresentation as a small business include fines of not more than $500,000 or imprisonment for not more than 10 years, or both; administrative remedies; and suspension and debarment as specified in subpart 9.4 of title 48, Code of Federal Regulations.

Location: (Optional)Please enter the following data for this location on this registration:

(M)Receipts (3 year average) at this Location______

(M)Number of Employees (12 months average) at this Location______

World-wide Organization: (M)Please enter the worldwide data for your organization to include parent, all affiliates, and all locations including your individual location. If you entered location information above, the numbers you enter for worldwide must be greater than or equal to the numbers entered in the location size:
Note if you do not have a World-Wide Organization, use the numbers listed from above.

Total (3 year average) Receipts______

Total Number (12 months average) of Employees______(Mandated by FAR CFR clause52.204-7)

Corporate Information

Type of Relationship with U.S. Federal Government (M) (Must Check One)

Contracts

Grants

Both (Contracts & Grants)

Type of Organization (M) (as defined by the IRS – must check one)

Corporate Entity, Not Tax Exempt (Firm pays Federal Income Taxes)

Corporate Entity, Tax Exempt (Firm does not pay Federal Income Taxes)

Partnership or Limited Liability Partnership

Sole Proprietorship

U.S. Government Entity (If selected, then choose one subgroup below)

Federal Government (If selected, choose all subgroups that apply)

Federal Agency

Federally Funded Research and Development Corporation

U.S. State Government

U.S. Local Government

(If selected, choose all subgroups that apply)

City

County

Inter-municipal

Local Government Owned

Municipality

School District

Township

Foreign Government

Tribal Government

International Organization

Other

Incorporation (M)if you selected “corporate entity” as type of organization)

State of Incorporation (USA only): ___

Country of Incorporation:______

Check if applicable.

Limited Liability Corporation

Subchapter S Corporation

Sole Proprietorship Point of Contact (M)if you selected “sole proprietorship” as Type of Organization)

Sole Proprietor Name:_____

US Phone:______Ext:______

Non-US Phone:_____ Ext:______

Fax:______

E-mail:______

Is your Business/Organization one of the following?

Foreign Owned and Located

Small Agricultural Cooperative

What is your Organization's Profit Structure? (M) You must select one of the following.

For-Profit Organization

Nonprofit Organization

Other Not for Profit Organization

If your business qualifies in one of the following Socio-Economic Categories, check all that reflect the current status of your business. Small Business status will automatically be derived from the receipts, number of employees, assets, or megawatt hours, and NAICS codes entered in the General Information portion of the registration.

Community Development Corporation Owned Firm

Labor Surplus Area Firm

These categories require that the firm is 51% owned and the management and daily operations are controlled by one or more members of the selected socio-economic group.

Self-Certified Small Disadvantaged Business

Veteran Owned

Service Disabled Veteran Owned

Woman OwnedIf you check this box, please check out is important that you comply with this correctly.

Minority Owned (must also choose one specific type)

Subcontinent Asian (Asian-Indian) American Owned

Asian-Pacific American Owned

Black American Owned

Hispanic American Owned

Native American Owned

Other than one of the preceding

Other Business Factors: Choose all that apply

Other Governmental Entities:

Airport Authority

Planning Commission

Council of Governments

Port Authority

Housing Authorities Public/Tribal

Transit Authority

Interstate Entity

Does your Organization qualify as one of the following? (Optional information, Check if the types apply to your organization.)

Community Development Corporation

Domestic Shelter

Educational Institution

Foundation

Hospital

Veterinary Hospital

If your Organization is an Education Entity, does it qualify as one of the following?
(Optional information, Check if the types apply to your organization.)

1862 Land Grant College

Private University or College

1890 Land Grant College

School of Forestry

1994 Land Grant College

State Controlled Inst of Higher Learning

Historically Black College or University (HBCU)

Tribal College

Minority Institutions

Veterinary College

Alaskan Native Servicing Institution (ANSI)

Hispanic Servicing Institution

Native Hawaiian Servicing Institution (NHSI)

What is the Nature of your organization's Business? (Optional information, Check all that apply)

Architecture and Engineering (A&E)

Construction Firm

Manufacturer of Goods

Research and Development

Service Provider

Is your business certified by a state certifying agency as a Department of Transportation (DOT) Disadvantaged Business Enterprise (DBE)?

Yes – DoT Certified DBE

If your organization is a Federally Recognized Native American Entity, check all that apply.)

Alaskan Native Corporation Owned Firm

Native Hawaiian Organization Owned Firm

American Indian Owned

Indian Tribe (Federally recognized)

Tribally Owned Firm

Goods and Services:

NAICS Codes(M)North American Industrial Classification Code to identify what product or service your business provides (6 digit numeric). Search on

NAICS Code:_NAICS Code:NAICS Code:

NAICS Code:NAICS Code:NAICS Code:

SIC Codes(M)Standard Industrial Classification Codes are no longer required for CCR.

Federal and Product Supply Codes(M)identify what type of activity your business performs (4 or 8 digit numeric). Search on view the Product and Service Code Info.

Code:Code:Code: Code:____Code:

Code:Code:Code:Code:Code:

Financial Information:(This information is REQUIRED, THIS IS HOW YOU GET PAID. I know from personal experience that you will get your money in less then 30 days when you include this. This information will NOT be made public. )

(M)Financial Institution Name:______

(Bank name for Electronic Funds Transfer)

(Required) ABA Routing Number (M) (9digits):

Note: your ABA routing number is the first set of number on your check. If your not sure call your bank or financial institution and they will be glad to give you the number.

Must indicate type of account (M)

(Required) Account Number(M): Checking OR Savings

Lockbox Number: (Optional)

Automated Clearing House (ACH=Bank) (M) at least one method of contact must be entered

ACH U.S. Phone Number (your bank):

ACH Fax (U.S. Only):

ACH Non-U.S. Phone:

ACH Email:

Remittance Address (M): (what is the “Remit to” name and address on your invoice/bill?)
Address to mail check to if EFT is temporarily unavailable.

Business Name (M):

Address (M):

City (M): State (M): Zip/Postal Code (M):

Province (all countries other than USA or Canada)______

Country (M):

Accounts Receivable Point of Contact (M):

Name (M):

Email (M):

U.S. Phone:Ext.:

Non U.S. Phone:Ext.:

Fax (U.S. Only):

Do you (the Registrant) use or accept Credit Cards Yes No

as a method of Purchase or Payment? (M).

Registration Acknowledgement and Point of Contact Information:

Note:_The Registrant acknowledges that the information provided is current, accurate, and complete.

CCR Primary Point of Contact (M)

Name:__

Email:

U.S. Phone:Ext.:

Non U.S. Phone:Ext.:

Fax (U.S. Only):

CCR Alternate Point of Contact(M)(If you use an alternate you must set them on a “user account”, they will receive an email they MUST respond to it.)

Check to use CCR Primary POC information for CCR Alternate POC

Name :

Email:

U.S. Phone:Ext.:

Non U.S. Phone: Ext.:

Fax (U.S. Only):

Government Business Point of Contact (M).

This POC and contact information (excluding the email address) will be publicly displayed on the CCR Search Page.

Name (M):

Email (M):

Address (M):

City (M): State (M): __Zip Code (M)______Country:______

Province (all countries other than USA or Canada)______

U.S. Phone (M):Ext.:

Non U.S. Phone (M):Ext.:

Fax (U.S. Only)(M):

WORKSMART: if you are a small one or two person company, you can use yourself has an alternate, but you really should have someone else that can be contacted if something goes wrong. If it’s just you, give your spouse that so that if anything happens to you, someone can get in and do what needs to be done.

Government Business Point of Contact Alternate (M) This POC and contact information(excluding the email address)will be publicly displayed on the CCR Search Page.

Check to use Primary Govt. POC information for Alternate Govt. POC

Name (M):

Email (M):

Address (M):

City (M): ______State (M):______Zip Code (M):_____ Country:______

Province (all countries other than USA or Canada)______

U.S. Phone (M):Ext.:

Non U.S. Phone (M):Ext.:

Fax (U.S. Only) (M):

Electronic Business Primary Point of Contact (M) This POC and contact information (excluding the email address) will be publicly displayed on the CCR Search Page.

Name (M):

Email (M):

Address (M):

City (M): ______State (M):______Zip Code (M):_____ Country:______

Province (all countries other than USA or Canada)______

U.S. Phone (M):Ext.:

Non U.S. Phone (M):Ext.:

Fax (U.S. Only) (M):

Electronic Business Alternate Point of Contact (M) This POC and contact information (excluding the email address) will be publicly displayed on the CCR Search Page.

Check to use Primary Electronic Business POC information for Alternate Electronic Business POC

Name (M):

Email (M):

Address (M):

City (M): ______State (M):______Zip Code (M):_____ Country:______

Province (all countries other than USA or Canada)______

U.S. Phone (M):Ext.: