*denotes a required field

* Contact Name:      (name to whom report will be mailed)

* Company:

* E-mail:

* Address:

   Address 2:

*City:     *ST:     * Zip:

*Telephone Number: (if extension use x after phone #)     FAX Number:

  EIN #:  

EIN (Employer Identification Number) is a unique number assigned by the IRS that will ensure consistency
of a company's name in a database. As our data collection progresses we will be able to provide
period over period reporting specifically for you by using this number. It will ensure correct
company identification and prevent errors such as X.Y.Z. Company versus XYZ Company, etc.
 

* Year & Quarter of the reported data:  2012     1

Please complete one of the following two sections.  Complete section one if you are entering only one set of CEI, DSO, Best Possible DSO and % Over 91 Days Past Due for one SIC or multiple SICs.  Complete section two if you are entering distinct CEI, DSO, Best Possible DSO and % Over 91 Days Past Due figures for multiple SICs.

SECTION 1

If your company has one, or more than one, SIC code - and you do not have separate receivable statistics - please complete Section 1.

SIC Number:     Find your SIC Code by Industry Name    Find your SIC Code by Industry (Numeric SIC listing)

If other SIC numbers apply to the data entered below, indicate the SIC numbers here: