Vendor Annual Return Form


------------------------LICENSE VENDOR TYPE------------------------

SOFTWARE VENDORS
Please indicate the number of customers you currently supply ISBT 128 compliant software to:






LABEL VENDORS
Please indicate the number of preprinted labels you supply each year:




VENDOR COMBINED (Software and Other)
Do you provide both software and non-software products/services that use ISBT 128 to 10 or more customers?
    


GENERAL VENDOR
Do you supply products that use ISBT 128 data structures?
    

----------------LIMITED USE LICENSE VENDOR TYPE---------------

CONSULTANT
Do you provide consultancy services related to the implementation and/or use of ISBT 128?
    


APPLICATION SERVICE PROVIDERS
Please indicate the number of customers you currently supply ISBT 128 compliant services via a software application:
        

_____________________________________________________

VENDOR INFORMATION
ICCBBA Vendor Identification Code (e.g., AAA):
*
Vendor Name (EXACTLY as it should appear in our database):
*
Address:
*
City:
*
State/Province:
*
Postal Code:
*
Country:
*
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:
Secondary Phone Number: