Solicitation Mailing List Application

1. Type of Application Initial Revision

2. Date:

3. Submit to:

International Broadcasting Bureau
330 Independance Ave, SW
Washington, D.C. 20237

4. Applicant:

Name
Street Address
County
City
State
Zip Code

5. Type of Organization Corporation Individual Non-Profit Organization Partnership

6. Address for mailing solicitations (If other than above)

Name
Street Address
County
City
State
Zip Code

7. Name of Officers, Owners, or Partners

a. President	b. Vice President	c. Secretary
d. Treasurer	e. Owners or Partners

8. Affiliates of Applicant

Name	Location	Nature of Affiliation

9. Persons authorized to sign offers and contracts in you name (indicate if agent).

Name	Official Capacity	Area Code	Phone Number

10. Identify equipment, supplies and/or services on which you desire to make an offer (Use Product Services Codes)

11a. Size of Business	11.b Average Number of Employees (including affiliates) for four preceding calendar quarters	11c. Average annual sales or receipts for preceding three fiscal years
Small Business (complete 11b. & 11c.) Other than Small Business

12. Type of Ownership
Disadvantaged Business Woman-Owned Business

13 Type of Business
Manufacturer or Producer Surplus Dealer Research and Development
Construction Concern Service Establishment

14. DUNS No. TIN

15. How long in present business?

18. Security Clearance

For	Top Secret	Secret	Confidential	Granting Agency	Dates Granted
a. Key Personnel
b. Plant Only