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Fields marked with * are required.
OMB Control No.: 0625-0237
Expiration Date: 10/31/12

AccessAmerica BUSINESS SERVICE PROVIDER CONTACT AND COMPANY INFORMATION

Company Name:*  
Full Name:*  
Salutation:  
Title/Responsibility:*  
Company Address:*  
City:*  
State/Province:*  
Zip Code:*  
Country:*  
Phone*:  
Fax:  
Email:*  
Website:  
Number of Employees*  

CONTACT AND SERVICE INFORMATION AS IT SHOULD APPEAR ONLINE

Please enter your company’s contact information and company description in the following fields, as you would like the information posted on our online Business Service Provider directory.
Contact Full Name:*  
Title:*  
Contact Phone*:  
Contact Fax:  
Contact Email:*  
Company Address(If different than above address):  
City:  
State/Province:  
Zip Code:  
Country:  

Short Business Service Provider Description*

 
Please try to provide a short description, less than 75 characters.

Complete Business Service Provider Description*
Describe your company and the service you provide in 250 words or less. This description may be edited for length and clarity. Please e-mail an electronic copy of your logo as a .jpg or .gif document (save as web file) with a width of exactly 200 pixels and height of up to 200 pixels to your Commercial Service contact.

Business Service Provider Categories*
I agree to pay $400 for the first category, and $100 for each additional category I choose*

Please select applicable categories from the list provided below.

Trade References
Please provide at least two references of companies with whom you have conducted business, U.S. companies if possible.
How did you learn about this program?*

 

  

Public reporting for this collection of information is estimated to be 5 minutes per response, including the time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection of information are voluntary, and will be provided confidentially to the extent allowed by law. Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Clearance Officer, International Trade Administration, Department of Commerce, Room 4001, 14th and Constitution Avenue, N.W., Washington, D.C. 20230.