LABELER IDENTIFICATION CODEINFORMATION CHANGE FORM

To make changes to your existing LIC(s) complete this form & return it to our office.

Health Industry BusinessCommunications Council
2525 E. Arizona Biltmore Circle
Suite 127
Phoenix, AZ 85016
Tel: 602.381.1091
Email: info@hibcc.org
Web site: www.hibcc.org

Updated 7/23/2019

 LIC Change FormPURPOSE OF FORM: LABELER IDENTIFICATION CODE (LIC) CHANGES
Select Change Type: __ Name Change __ Address Change __Contact Change
CURRENT (OLD) INFORMATION:
LIC Number ____________________________________________________________________________________Organization Name__________________________________________________________________________
Division / Subsidiary__________________________________________________________________________Name of Official Representative__________________________________________________________________________Title__________________________________________________________________________
Phone #
Fax #__________________________________________________________________________
Number and Street__________________________________________________________________________
City/State/Zip Code/Country__________________________________________________________________________
E-Mail Address
By signing below I agree to this change and certify that the above information is correct and true
to the best of my knowledge.

Signature of Official Representative

Date-2-Updated 7/23/2019

 LIC Change FormNEW INFORMATION:(Please provide official documentation of any organization name changes)
LIC Number ____________________________________________________________________________________
Organization Name__________________________________________________________________________
Division / Subsidiary__________________________________________________________________________Name of Official Representative__________________________________________________________________________Title__________________________________________________________________________
Phone #
Fax #__________________________________________________________________________
Number and Street__________________________________________________________________________
City/State/Zip Code/Country__________________________________________________________________________
E-Mail Address
By signing below I agree to this change and certify that the above information is correct and true
to the best of my knowledge.

Signature of Official Representative

Date-3-

Updated 7/23/2019

 LIC Change Form
LIC Number __________LIC CHANGE FEE (in US Dollars):$50.00METHOD OF PAYMENT Please charge to my credit card account.  Visa

 MasterCard

 AmEx______________________________________________________________________________CREDIT CARD #EXPIRATION DATECSV/CID CODE______________________________________________________________________________CARDHOLDER’S NAME (as it appears on the card)
SIGNATURE______________________________________________________________________________CARDHOLDER’S ADDRESS______________________________________________________________________________CARDHOLDER’S CITYSTATE
ZIP/POSTAL CODE
 A check made payable to HIBCC is enclosed.
 Please Invoice Me – Purchase Order # ___________________________________________________________________________________________
Signature of Official RepresentativeTitle_________________________
Date
Legal Notice: All fees are non-refundable.

FOR OFFICE USE ONLY:______________________________________________________________________________
Date Received Form
Date Received Payment
Date Changes Entered-4-