General Information about this Facility

General Information about thí Facility

Legal Company Name:

Legal Entity Type:

Corporation Identification Number:

List all trade Names:

Is your Corporation owned by a Parent Company or Group?

Yes

If you selected “Yes”, please provide parent company information

Parent Company Name:

Facility Street Address:

State:

City:

Postal Code:

Country:

Facility Telephone:

Fax:

Email:

Website:

Emergency Contact Representative:

Contact’s Title:

Contact’s Email:

Contact’s Mobile:

FDA Registration Number (if applies):

FDA PIN (if applies):

DUNS Number (if applies):

General Product Categories:

Human

Animal

Both

Product Name: