Agricultural Marketing Service 

Science and Technology Program, National Science Laboratories 

Request for Customer Information 

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to 

respond to, a collection of information unless it displays a valid OMB control number. This valid OMB control number for this 

collection is 0581-xxxx. The time required to complete this information collection is estimated to average 5 minutes per response, 

including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and 

completing and reviewing the collection information. 

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C.522a) and the Paperwork Reduction Act of 

1995. The authority for requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, 

Secs. 1-19, 48 Stat.31, as amended, (7 U.S.C. 601-674). Furnishing the requested information is necessary for the administration 

of the marketing order program. 

Check One: 

New Customer 

Update Existing Customer Acct# __________ 

Type of Business (Check All That Apply): 

Small Business Women-Owned 

Veteran-Owned Minority-Owned 

Customer Name (As registered with the IRS) Federal Tax ID Number* 

Doing Business As (If applicable) 

Billing Address Line 1 Physical Address Line 1 

Billing Address Line 2 Physical Address Line 2 

City State Zip Code + 4 City State Zip Code + 4 

Country Country 

Account Contact: Account Contact Phone: 

Account Contact E-mail: Account Contact Fax: 

Remarks: 

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or 

administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, 

family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases 

apply to all programs). Remedies and complaint filing deadlines vary by program or incident. 

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's 

TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. 

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write 

a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) 

mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: 

program.intake@usda.gov. 

USDA is an equal opportunity provider, employer, and lender. 

Customer Signature Date: 

Customer Phone: Customer Fax: Customer E-Mail: 

Submit Completed Form to: 

National Science Laboratories (NSL) PHONE: 704-867-3873 

801 Summit Crossing Place, Ste. B FAX: 855-296-1230 

Gastonia, NC 28054 Email: NationalScienceLaboratories@usda.gov

* For U.S. Customers only. This is the Corporate Tax ID number unless the Customer is an individual, then the Social Security Number is required. 

TO BE COMPLETED BY AMS PROGRAM OFFICE 

Received By Date Received Processed By Date Processed Provide Customer Access 

to Electronic Systems 

AMS System AMS System Customer Number NFC Customer Number Customer Type Sales Office Type of Billing: 

COD Monthly 

FORM# (Reproduce locally)