DateIssued:NameofLicensee/Vendor:Licensee/Vendor#:Region:NameofFactory:Factory#:PhysicalAddress:MailingAddress:Telephone#:Fax#:NameofContact:FacilityName:PhysicalAddress:MailingAddress:Telephone#:Fax#:(Pleasereviewinformationabove,makechangesonformifnecessary
)FACTORY:OwnershipTypeofFactory:JointVenture_____Partnership_____Corporation_____PrivatelyOwned_____ForeignInvestment_____Other________________________________________NameofBroker/Agent(ifapplicable):MailingAddress:Telephone#:Fax#:FACILITY(Note:Completeaquestionnaireforeachfacilitylocation)OwnershipTypeofFacility:JointVenture_____Partnership_____Corporation_____PrivatelyOwned_____ForeignInvestment_____Other_____________________________________________YearFacilityEstablished:NameofPlantManager:Telephone#:Fax#:ArticlesProduced:TotalEmpl