LIC Application Form (Online)

PURPOSE OF APPLICATION: LABELER IDENTIFICATION CODE (LIC) ASSIGNMENT

Primary Organization

Primary Organization Name(Required)

Division / Subsidiary

Name of Official Representative(Required)

First Last

Title

Telephone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of CEO(Required)

First Last

Title

Phone(Required)

CEO's Email Address(Required)

Same as above

Other

CEO Address

if different from above

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Organization

Choose applicable box for primary market(Required)

Manufacturer of Goods & Services

Distributor/Wholesaler

Please choose option for your primary market(Required)

Medical

Dental

LABELER FEES

Labeler Identification Code (LIC) Assignment

Choose the appropriate box corresponding to the gross global sales of all products/devices labeled with your organization's name or brand.(Required)

Gross sales up to $2 million ($1,000.00)

Gross sales up to $5 million ($1,500.00)

Gross sales up to $10 million ($2,500.00)

Gross sales up to $30 million ($4,000.00)

Gross sales up to $60 million ($5,000.00)

Gross sales up to $100 million ($7,500.00)

Gross sales up to $150 million ($9,000.00)

Gross sales up to $500 million ($12,000.00)

Gross sales above $500 million ($20,000.00)

LIC Fee

Certification Report

Please certify your most recent calendar or fiscal year sales level.

For All Manufacturers: Fee for the LIC is computed on the principle of gross sales to the health care industry. In calculating sales, include sales of all divisions and sales to other manufacturers.

For All Distributors/Wholesalers: Fee for the LIC is computed on the principle gross sales of private labeled packaged products.

THIS INFORMATION WILL BE TREATED ON A CONFIDENTIAL BASIS

Specify annual sales $

in U.S. Dollars

For the most recent calendar or fiscal year:

Year

CERTIFICATION REPORT

Please certify your most recent fiscal year sales level. Applicants are required to submit one of the following from the last fiscal/calendar year: Dun & Bradstreet Report, Profit & Loss Statement, or page 1 of your company’s Corporate Tax Return (and any related documents). This information will be kept confidential and will only be used to determine the LIC fee. (All supporting documents must be in English)

Drop files here or

Accepted file types: pdf, doc, jpg, Max. file size: 200 MB, Max. files: 5.

Our organization hereby applies for assignment/registration of a Labeler Identification Code from the Health Industry Business Communications Council.

In making such application, we agree to be bound by all rules and regulations of the Council including, but not limited to the Articles of Incorporation, the Bylaws, the Health Industry Bar Code Standard, and any and all other rules and regulations which the Council has now or may hereafter adopt concerning the use of the Health Industry Bar Code Standard and the Labeler Identification Code assigned. The Council will notify us of our assigned Labeler Identification Code upon receipt of our application fee and Council approval of our completed application.

Our organization hereby agrees to indemnify, and hold harmless, the Health Industry Business Communications Council and their officers, directors, employees, agents, successors and assigns from any and all claims, losses, damages, and liabilities whatsoever resulting from the use or misuse of the Health Industry Bar Code Standard and our assigned Labeler Identification Code.

We understand and acknowledge that the Council has taken all reasonable precautions to prevent the assignment of duplicate Labeler Identification codes. If duplicate codes are assigned, the liability of the Council shall be limited to a refund of the application’s Labeler Identification Code fee or the actual damages, if any, whichever is less.

Name(Required)

Date(Required)

Payment

Amount to Pay

Method of Payment

Choose an option(Required)

Pay by Credit Card

Please invoice me directly

Mailing a check or money order

EFT/ACH/Wire Transfer

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Purchase Order #

Check Number #

Please mail check and money orders to:

HIBCC
2525 E Arizona Biltmore Circle, Suite 127
Phoenix, Arizona 85016

Billing Company Name(Required)

Billing Contact(Required)

First Last

Billing Email Address(Required)

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

**Before clicking the ‘submit’ button, make sure that all the required fields are filled out.

Phone

This field is for validation purposes and should be left unchanged.

602-381-1091

info@hibcc.org

The Health Industry Business Communications Council

LIC Application Form (Online)

Primary Organization

Type of Organization

LABELER FEES

Labeler Identification Code (LIC) Assignment

Certification Report

THIS INFORMATION WILL BE TREATED ON A CONFIDENTIAL BASIS

Payment

Method of Payment

**Before clicking the ‘submit’ button, make sure that all the required fields are filled out.

HIBCC Labelers