Form CFS-0001 2012 Commodity Flow Survey - Advanced Questionnaire

Attachment A1

DRAFT
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
FORM

2012 Commodity Flow Survey
Advanced Questionnaire

CFS-0001(2012)

(08-16-2010) Draft 2

OMB No. XXXX-XXXX: Approval Expires 00/00/20XX

DUE DATE:

Internet Address:

Username:

Password:

YOUR RESPONSE IS REQUIRED BY LAW. Title 13, United States Code, requires businesses and other organizations that receive
this form to answer the questions and return the report to the U.S. Census Bureau. By the same law, YOUR U.S. CENSUS BUREAU
REPORT IS CONFIDENTIAL. It may be seen only by persons sworn to uphold the confidentiality of U.S. Census Bureau information
and may be used only for statistical purposes. Further, copies retained in respondents’ files are immune from legal process.

1

VERIFICATION OF SHIPPING ACTIVITY
Does this establishment:
a. Ship or deliver products from this location to customers or clients?

1

Yes

2

No

b. Ship or deliver products from this location to other locations of this company?

1

Yes

2

No

c. Provide for customer pickup of products from this location?

1

Yes

2

No

If you answer "Yes" to any of the three questions, proceed to Section 2 .
If you answered "No" to all of the questions, proceed to Section 5 .

2

VERIFICATION OF SHIPPING ADDRESS

1

Yes, this is the address from which this establishment ships. (Proceed to Section 3.)

2

No, this establishment ships from another address. (Enter the correct shipping address in 2b.)

b. Corrections to Shipping Address.
Company Name

12012019

§-"54¤

a. Is the address below the correct address from which this establishment ships?

Address 1

Address 2

City

USCENSUSBUREAU

State

Zip Code

3

VERIFICATION OF MAILING ADDRESS
a. Mark one of the following:
1

Mail the CFS questionnaires to the establishment’s shipping address, as listed in 2a or 2b. (Proceed to Section 3c.)

2

Mail the CFS questionnaires to the address for this establishment entered in 3b.

b. Mailing Address.
Company Name

Address 1

Address 2

State

City

Zip Code

c. Provide the name and title of the individual who could best give information about the shipments made from this
establishment.
Name

Title

4

ANNUAL VALUE OF SHIPMENTS
Mark the box that best represents your estimate of the total annual value of all shipments originating
from this location (verified or corrected in Section 2).

5

$0, establishment had no shipments

$50 million or more but less than $200 million

More than zero but less than $1 million

$200 million or more but less than $500 million

$1 million or more but less than $5 million

$500 million or more but less than $1 billion

$5 million or more but less than $20 million

$1 billion or more but less than $5 billion

$20 million or more but less than $50 million

$5 billion or more

Provide the name and phone number of the individual completing this form.
Contact Name

Area Code

Extension

REMARKS

Form CFS-0001(2012)

12012027

§-"5<¤

6

Contact Number

(08-16-2010) Draft 2

2