Associated Facility Annual Return Form

The Associated Facility Annual Return Form is for Facility Identification Numbers (FINs) associated with a main facility. You may complete this form as many times as needed for the additional facilities.

*For US facilities registered and/or licensed with the FDA, the name and location of your facility should match what appears on your FDA registration or license.

FACILITY INFORMATION
ISBT 128 Facility Identification Number:
*
Facility Type (check all that apply):
                          
*
Facility Name (EXACTLY as it should appear in our database):
*
Facility Address:
*
City:
*
State/Province:
*
Postal Code:
*
Country:
*

__________________________________

CONTACT INFORMATION
Primary Contact Name (including Job Title):
*
Primary Contact Email Address
*
Phone Number:
*
Fax Number:
Web Address:
Secondary Contact Name (including Job Title):
Secondary Contact Email Address: