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    PURPOSE OF APPLICATION: LABELER IDENTIFICATION CODE (LIC) ASSIGNMENT

    Labeler’s Information





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    Street Address


    Address line 2


    City


    State/Province/Region


    Zip/Postal Code


    Country



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    Last




    if different from above


    Street Address


    Address line 2


    City


    State/Province/Region


    Zip/Postal Code


    Country


    same as aboveOther

    Type of Organization


    Manufacturer of Goods & ServicesDistributor/Wholesaler


    MedicalDentalAnimal

    LABELER FEES


    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)

    Certification Report

    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, but do not include intracompany sales.

    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

    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)



    In U.S. Dollars



    Year




    Our (Client) 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.

    The Invoice will be emailed to the billing information below.


    Billing Information




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    Street Address


    Address line 2


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    State/Province/Region


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