Central Contractor Registration Form

Central Contractor Registration Worksheet

You may use this CCR Worksheet to collect the information required to register in CCR, then go to www.ccr.gov to register.

(M) = Mandatory field. Data must be entered for registration to be complete.

General Information

DUNS Number¹(M): CAGE Code² (M) if foreign: __________________

Legal Business Name (M):

Doing Business As:

Tax ID ³ (M): ___ OR Social Security Number:

Division Name: ___________ Division Number:

Corporate Web Page URL (Company website address):
Example: http://www.example.com or http://example.com

Physical Address (M): ________________________________

City (M): ___________________ State (M): __________

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): _____

Zip/Postal Code: ______Zip Plus 4 (M): _____ Country (M): ________

Business Start Date (M)(mm/dd/yyyy): ____________ Number of Employees (M): ______

Fiscal Year Close Date (M) (mm/dd): ________ Annual Revenue (M):__________

Type of Organization (M):

Corporate Entity (Not Tax Exempt) _______ Corporate Entity (Tax Exempt) _______

State of Incorporation (M): _________ or Country (if other than US): ___________

Sole Proprietorship Partnership U.S. Government Entity --

Federal
State Local
Foreign Government
International Organization
Other ____________________________

Owner Information (M) if Sole Proprietorship:

Name: __________________________________________

U.S. Phone: __________________________ Ext.: _____________

Non U.S. Phone: __________________________ Ext.: ____________

Fax (U.S. Only): _________________________

Email: ______________________________

Business Type(s) (M) Check all that apply:

8(a) Program Participant (also check small business)
American Indian Owned
Hub Zone Business (also check small business)
Minority Owned Business (Must choose one below):

Subcontinent Asian (Asian-Indian) American
Asian-Pacific American
Black American
Hispanic American
Native American
No Representation/None of the above

Large Business
Small Business
Small Disadvantaged Business (also check small business)
Woman Owned Business
Veteran Owned Business
Service Disabled Veteran Owned
Construction Firm
Educational Institution
Emerging Small Business
Foreign Supplier
Historically Black College/Univ.
Labor Surplus Area Firm
Limited Liability Company
Manufacturer of Goods
Minority Institution
Municipality
Nonprofit Institution
Research Institute
S Corporation
Service Location
Sheltered Workshop (JWOD)
Tribal Government

Party Performing Certification (M) if approved for 8(a) certification through the Small Business Administration (SBA)

Certifier’s Name: ________________________________

Address: ______________________________________

City: _____________________ State: ______ Zip/Postal Code: _______

Country: _______________

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 http://www.census.gov/epcd/www/naics.html

NAICS Code: _____ NAICS Code: _____ NAICS Code: _____

SIC Codes (M) Standard Industrial Classification Codes identify what type of activity your business performs (4 or 8 digit numeric). Search on http://www.osha.gov/oshstats/sicser.html

SIC Code:_____ SIC Code: _____ SIC Code: _____

Financial Information:
EFT –Electronic Funds Transfer Information

Financial Institution Name: ________________________________
(Bank name for Electronic Funds Transfer) (If Non-US business, EFT is optional)

ABA Routing Number (M) (9digits): ________________________
Must indicate type of account (M)

Account Number (M): ____________________________ Checking OR Savings

Lockbox Number: ____________________

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

ACH U.S. Phone Number: ____________________________________

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?)

Business Name (M): ________________

Address (M): ___________

City (M): _____________ State (M): _____ Zip/Postal Code (M): _______ Country (M): __________

Accounts Receivable Contact (M): ________________________________________

Name (M): __________________________________________

Email (M): ________________________________________

U.S. Phone (M): __________________________ 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 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)

Name: __________________________________________

Email: _____________________________________

U.S. Phone: ______________________________ Ext.: ______________

Non U.S. Phone: __________________________ Ext.: ______________

Fax (U.S. Only): ________________________

For the following POCs, may identify two persons for each category
Government Business Point of Contact (If name is entered, all fields are mandatory)

Name: _____________________________________________

Email: ___________________________________

Address: ___________________________________________________

City: ______________________________ State:_________ Zip Code:_____________

U.S. Phone: _____________________ Ext.: _____________

Non U.S. Phone: ____________________ Ext.: _____________

Fax (U.S. Only): ____________________

Government Business Point of Contact Alternate- if primary is entered, alternate is mandatory
Check to use Primary Govt. POC information for Alternate Govt. POC

Name: ______________________________________________

Email: _______________________________

Address: ___________________________________________________

City: ______________________________ State:_______ Zip Code:_____________

U.S. Phone: __________________________ Ext.:_____________

Non U.S. Phone: ______________________ Ext.: _____________

Fax (U.S. Only): _________________________

Electronic Business Point of Contact (M)

Name (M): ___________________________________

Email (M): ______________________________

Address (M): __________________________________________________

City (M): ___________________________ State (M): ______ Zip (M): _____________

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

Non U.S. Phone: ________________________ Ext.: ___________

Fax (U.S. Only): __________________

Electronic Business Point of Contact Alternate (M)
Check to use Primary EB POC information for Alternate EB POC

Name (M): _________________________________________

Email (M): _________________________________

Address (M): __________________________________________________

City (M): ___________________________ State (M): ________ Zip (M):________

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

Non U.S. Phone: ________________________ Ext.: _____________

Fax (U.S. Only): _________________

Past Performance Point of Contact
(If name is entered, all fields are mandatory)(PPIRS)
Note: MPIN is mandatory if entering Past Performance POC

Name: ________________________________________

Email: ______________________________

Address: __________________________________________________

City: _____________________________ State: __________ Zip Code: ________

U.S. Phone: Ext.:

Non U.S. Phone: ___________________ Ext.: _____________

Fax (U.S. Only): __________________________

Past Performance Point of Contact Alternate
(If primary is entered, alternate is mandatory)(PPIRS) -- Check to use Primary Past Perf. POC information for Alternate Past Perf. POC

Name: ____________________________

Email: __________________________

Address: __________________________________________________

City: _____________________________ State: _____________ Zip Code: _____________

U.S. Phone: __________________________ Ext.: __________

Non U.S. Phone: ___________________________ Ext.: ___________

Fax (U.S. Only): _________________________

Marketing Partner ID (MPIN) _________________
Must be 9 alphanumeric, no spaces, no symbols -- MPIN is Mandatory if entering Past Performance POC.

You may enter your registration directly on the web at www.ccr.gov

Read the CCR Handbook http://www.ccr.gov/handbook.cfm for further information.

E-mail address CCR@dlis.dla.mil

For registration assistance call 1-888-227-2423 or 1-269-961-4725