**REIMBURSABLE AGREEMENT CUSTOMER PROFILE FORM**

The Reimbursable Customer Profile has been developed to provide one form
for necessary information for customers and contacts which need to be
established in the Bureau of Industry (BIS) and National Oceanic and
Atmospheric Administration (NOAA) Core Financial System (CFS) customer
database [prior]{.underline} to the establishment of a reimbursable
agreement. This information will be used by NOAA only for the purposes
stated above and access to this data will be restricted to authorized
personnel who may only use the information for those specified purposes.
The form should be completed by the Line Office responsible for the
agreement and submitted to the Finance Office for inclusion in the
database of those customers and contacts who have not yet been
established in the CFS.

Unless otherwise noted, only the italicized fields on the form need to
be completed for an individual customer (Consumer).

+-------------------+--------------------------------------------------+
| **[Field          | **[Description]{.underline}**                    |
| Na                |                                                  |
| me]{.underline}** |                                                  |
+-------------------+--------------------------------------------------+
| ***New or         | Check the box which indicates if the form is for |
| Change***         | a new Customer Profile or to change a customer   |
|                   | profile.                                         |
|                   |                                                  |
|                   | *Note: If the profile is a change, complete the  |
|                   | Name field and those fields which have changed.  |
|                   | The other fields should remain blank.*           |
+-------------------+--------------------------------------------------+
| ***[\_\           | Enter the full name of the customer              |
| _\_\_\_\_\_\_\_\_ |                                                  |
| \_\_\_\_\_\_\_\_\ |                                                  |
| _]{.underline}*** |                                                  |
|                   |                                                  |
| ***[NAME          |                                                  |
| :]{.underline}*** |                                                  |
|                   |                                                  |
| ***Legal Name***  |                                                  |
+-------------------+--------------------------------------------------+
| ***Di             | Enter the division and/or subunit the customer   |
| vision/subunit*** | represents.                                      |
|                   |                                                  |
|                   | *Note: This field does not apply to Individual   |
|                   | customers/Consumers.*                            |
+-------------------+--------------------------------------------------+
| ***Acronym or     | Enter the commonly known acronym or name for the |
| shortened name*** | customer.                                        |
|                   |                                                  |
|                   | *Note: This field holds a maximum of 6           |
|                   | alphanumeric characters.*                        |
+-------------------+--------------------------------------------------+
| ***Type of        | Check the Customer type for the customer.        |
| Customer***       |                                                  |
|                   | *Note: The list of valid customer types can be   |
|                   | found on the form. Check only one customer       |
|                   | type.*                                           |
+-------------------+--------------------------------------------------+
| ***Agency         | Enter the unique agency location code assigned   |
| Location Code     | by the Department of Treasury for the bureau     |
| (ALC)***          | that will issue the bills.                       |
|                   |                                                  |
|                   | *Note: This field is for federal government      |
|                   | agencies only.*                                  |
+-------------------+--------------------------------------------------+
| ***Bill through   | Check the 'Yes' box if the bill will be          |
| IPAC?***          | processed through the Intragovernmental Payments |
|                   | and Collections (IPAC) system; otherwise check   |
|                   | the 'No' box..                                   |
+-------------------+--------------------------------------------------+
| ***Taxpayer       | Enter the unique taxpayer identification number  |
| Identification    | (TIN) assigned by the Department of Treasury for |
| Number (TIN)***   | the customer.                                    |
|                   |                                                  |
|                   | *Note: The TIN number is totally numeric and     |
|                   | requires the format of 999-99-9999* or           |
|                   | 99-9999999.                                      |
+-------------------+--------------------------------------------------+
| ***SSN            | Enter the unique social security number assigned |
| (individual/sole  | by the Department of Treasury if the customer is |
| p                 | an individual or sole proprietorship.            |
| roprietorship)*** |                                                  |
|                   | *Note: The SSN is totally numeric and requires   |
|                   | the format of 999-99-9999.*                      |
+-------------------+--------------------------------------------------+
| ***EIN            | Enter the unique Employer Identification Number  |
| (Corporation/     | (EIN) assigned by the Department of Treasury if  |
| partnership/sole  | the customer is a corporation, partnership or    |
| proprietorship    | sole proprietorship with one or more employees.  |
| with one or more  |                                                  |
| employees***      | *Note: The EIN is totally numeric and requires   |
|                   | the format of 99-9999999.*                       |
+-------------------+--------------------------------------------------+
| ***Parent Company | Enter the customer's Parent Company Name.        |
| Name***           |                                                  |
+-------------------+--------------------------------------------------+
| ***Parent***      | Enter the unique Employer Identification number  |
|                   | (EIN) of the Parent Company.                     |
| ***Company***     |                                                  |
| ***EIN***         | *Note: The EIN is totally numeric and requires   |
|                   | the format of 99-9999999.*                       |
+-------------------+--------------------------------------------------+
| **[\_             | Enter the name of the customer sponsoring the    |
| \_\_\_\_\_\_\_\_\ | reimbursable agreement                           |
| _\_\_\_\_\_\_\_\_ |                                                  |
| \_]{.underline}** |                                                  |
|                   |                                                  |
| **[Customer Name  |                                                  |
| and Billing       |                                                  |
| Contact Name and  |                                                  |
| Addre             |                                                  |
| ss]{.underline}** |                                                  |
|                   |                                                  |
| ***\*Customer     |                                                  |
| Name***           |                                                  |
+-------------------+--------------------------------------------------+
| ***\*Contact Name | Enter the name of the billing contact for the    |
| and/or Title***   | reimbursable agreement or the title of the       |
|                   | billing contact.                                 |
+-------------------+--------------------------------------------------+
| ***\*Address Line | Enter the first line of the mailing address for  |
| 1***              | the customer.                                    |
+-------------------+--------------------------------------------------+
| ***Address Line   | A 2^nd^ address line is available if needed      |
| 2***              |                                                  |
+-------------------+--------------------------------------------------+
| ***\*City***      | Enter the name of the city of the mailing        |
|                   | address for the customer                         |
+-------------------+--------------------------------------------------+
| ***\*State***     | Enter the state of the mailing address for the   |
|                   | customer                                         |
+-------------------+--------------------------------------------------+
| ***\*ZIP***       | Enter the 5 digit zip code for the above         |
|                   | address.                                         |
+-------------------+--------------------------------------------------+
| ***\*Country***   | Enter the country of the customer.               |
+-------------------+--------------------------------------------------+
| ***\*DUNS         | Enter the unique nine digit identification       |
| Number***         | number provided by Dun & Bradstreet. The DUNS    |
|                   | number is site specific. Therefore, each         |
|                   | distinct physical location of an entity such as  |
|                   | branches, divisions, and headquarters, may be    |
|                   | assigned a separate DUNS number.                 |
+-------------------+--------------------------------------------------+
| ***Phone \#***    | Enter the phone number for the customer contact. |
+-------------------+--------------------------------------------------+
| ***Fax \#***      | Enter the fax phone for the customer contact.    |
+-------------------+--------------------------------------------------+
| ***Internet       | Enter the e-mail address for the customer        |
| E-mail address*** | contact.                                         |
+-------------------+--------------------------------------------------+
| **[\_             | Enter the name of the acceptance contact for the |
| \_\_\_\_\_\_\_\_\ | reimbursable agreement or the title of the       |
| _\_\_\_\_\_\_\_\_ | acceptance contact.                              |
| \_]{.underline}** |                                                  |
|                   |                                                  |
| **[Acceptance     |                                                  |
| Contact Name and  |                                                  |
| Addre             |                                                  |
| ss]{.underline}** |                                                  |
|                   |                                                  |
| ***\*Contact Name |                                                  |
| and/or Title***   |                                                  |
+-------------------+--------------------------------------------------+
| ***\*Address Line | Enter the first line of the mailing address for  |
| 1***              | the acceptance contact.                          |
+-------------------+--------------------------------------------------+
| ***Address Line   | A 2^nd^ address line is available if needed.     |
| 2***              |                                                  |
+-------------------+--------------------------------------------------+
| ***\*City***      | Enter the name of the city of the mailing        |
|                   | address for the acceptance contact.              |
+-------------------+--------------------------------------------------+
| ***\*State***     | Enter the state of the mailing address for the   |
|                   | acceptance contact.                              |
+-------------------+--------------------------------------------------+
| ***\*ZIP***       | Enter the 5 digit zip code for the above         |
|                   | address.                                         |
+-------------------+--------------------------------------------------+
| ***\*Country***   | Enter the country of the acceptance contact.     |
+-------------------+--------------------------------------------------+
| ***\*DUNS         | Enter the unique nine digit identification       |
| Number***         | number provided by Dun & Bradstreet. The DUNS    |
|                   | number is site specific. Therefore, each         |
|                   | distinct physical location of an entity such as  |
|                   | branches, divisions, and headquarters, may be    |
|                   | assigned a separate DUNS number.                 |
+-------------------+--------------------------------------------------+
| ***Phone \#***    | Enter the phone number for the acceptance        |
|                   | contact.                                         |
+-------------------+--------------------------------------------------+
| ***Fax \#***      | Enter the fax phone for the acceptance contact.  |
+-------------------+--------------------------------------------------+
| ***Internet       | Enter the e-mail address for the acceptance      |
| E-mail address*** | contact.                                         |
+-------------------+--------------------------------------------------+
| **[\_             | Enter the name of the financial reporting        |
| \_\_\_\_\_\_\_\_\ | contact for the reimbursable agreement or the    |
| _\_\_\_\_\_\_\_\_ | title of the financial reporting contact.        |
| \_]{.underline}** |                                                  |
|                   |                                                  |
| **[Financial      |                                                  |
| Reporting Contact |                                                  |
| Name and          |                                                  |
| Addre             |                                                  |
| ss]{.underline}** |                                                  |
|                   |                                                  |
| ***\*Contact Name |                                                  |
| and/or Title***   |                                                  |
+-------------------+--------------------------------------------------+
| ***\*Address Line | Enter the first line of the mailing address for  |
| 1***              | the financial reporting contact.                 |
+-------------------+--------------------------------------------------+
| ***Address Line   | A 2^nd^ address line is available if needed.     |
| 2***              |                                                  |
+-------------------+--------------------------------------------------+
| ***\*City***      | Enter the name of the city of the mailing        |
|                   | address for the financial reporting contact.     |
+-------------------+--------------------------------------------------+
| ***\*State***     | Enter the state of the mailing address for the   |
|                   | financial reporting contact.                     |
+-------------------+--------------------------------------------------+
| ***\*ZIP***       | Enter the 5 digit zip code for the above         |
|                   | address.                                         |
+-------------------+--------------------------------------------------+
| ***\*Country***   | Enter the country of the financial reporting     |
|                   | contact.                                         |
+-------------------+--------------------------------------------------+
| ***\*DUNS         | Enter the unique nine digit identification       |
| Number***         | number provided by Dun & Bradstreet. The DUNS    |
|                   | number is site specific. Therefore, each         |
|                   | distinct physical location of an entity such as  |
|                   | branches, divisions, and headquarters, may be    |
|                   | assigned a separate DUNS number.                 |
+-------------------+--------------------------------------------------+
| ***Phone \#***    | Enter the phone number for the financial         |
|                   | reporting contact.                               |
+-------------------+--------------------------------------------------+
| ***Fax \#***      | Enter the fax phone for the financial reporting  |
|                   | contact.                                         |
+-------------------+--------------------------------------------------+
| ***Internet       | Enter the e-mail address for the financial       |
| E-mail address*** | reporting contact.                               |
+-------------------+--------------------------------------------------+

\* **Required information**

+------------+---------------------------------------------------------+
| ***Certifi |                                                         |
| cation:*** |                                                         |
+------------+---------------------------------------------------------+
| ***NOAA    | The form should be signed by the NOAA individual        |
| ind        | responsible for filling out this form along with their  |
| ividual*** | typed name, title and date of signature.                |
|            |                                                         |
| ***who     |                                                         |
| filled out |                                                         |
| the        |                                                         |
| form***    |                                                         |
+------------+---------------------------------------------------------+