ICCBBA - APPLICATION FOR FACILITY REGISTRATION-FINAL

ICCBBA - APPLICATION FOR FACILITY REGISTRATION

FM-025 v26
- REGISTRATION PROCESSING WILL TAKE APPROXIMATELY 2 – 4 WEEKS
- If you are unable to submit the completed form online, please submit completed form to ICCBBA, P.O. Box 11309, San Bernardino, CA 92423-1309 USA
If you need assistance with completing this form, please email our staff registration@iccbba.org or call +1 909 793 6516.
Please check one of the following:

New FacilityRe-registration of FINRequesting additional FIN(s) to an existing registration.
Re-registration of FIN
If you chose "Re-registration of FIN" please complete this field
Link to FIN
If you chose "Requesting additional FIN(s) to an existing registration," you must complete this field *
1. Facility’s Full Legal Name*
2. Primary Contact Person to Whom Mailings Should be Sent*

First NameSurname
Job Title*
E-mail (Primary)*
example@example.com
3. Secondary Contact Person*

First NameSurname
Job Title*
E-mail (Secondary)*
example@example.com
4. Legal Business Address of Firm
Country*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Telephone, Fax, and Website
Country Code*
Tel*
Fax
Website Address:
8. Billing Address
Department*
Email (Billing)*
example@example.com
Country*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Registration Fee: Please see below for fees.
Additional FIN(s) Fee: $250.00

For each subsequent Facility Identification Number Requested.
Plasma Fractionator or Further Processing Facilities

*Please check the type that applies to you.
Plasma Fractionators who read and interpret ISBT 128 bar codes

Select if applicable
Registration Fee: None

Annual License Fee: $9,014.12

Plasma fractionators who read and interpret ISBT 128 donation identification numbers and/or product codes, whether originating from their own collection or from a third-party supplier, are required to register with ICCBBA and pay an annual license fee.
Plasma Fractionators who label plasma donations with ISBT 128 bar codes

Select if applicable
Registration Fee: $250.00

Annual License Fee: Will be billed based on the total number of Donation Identification Numbers (DINs) assigned annually. For facilities that label final products, indicate the number of final products labeled annually with ISBT 128. The fee is US$0.0215 per unit, with a minimum license fee of $502.63.

Plasma fractionators who want to use ISBT 128 donation numbers on the plasma that they collect will need to register as collection facilities and be assigned a facility identification number.
Provide activity in your facility for your last complete fiscal year. If this includes more than one site, please include all sites, and provide one aggregate number
Plasma Fractionators who label derivatives with ISBT 128 or Further Processing Facilities

Select if applicable
Registration Fee: None

Annual License Fee: Will be billed based on the total number of Donation Identification Numbers (DINs) assigned annually. For facilities that label final products, indicate the number of final products labeled annually with ISBT 128. The fee is US$502.63, plus $0.0215 for each unit over 20,000.

Plasma fractionators or Further Processing Facilities who supply final product labeled with ISBT 128 are required to register with ICCBBA and pay an annual license fee.

The annual bill is calculated as follows:

For plasma derivatives other than solvent detergent plasma, the fee has not yet been determined (contact the ICCBBA of f ice for more information).
Provide activity in your facility for your last complete fiscal year. If this includes more than one site, please include all sites, and provide one aggregate number

8. Number of additional Facility Identification Numbers requested:
9. What software solution is your facility using (if any) or planning on using?
Please enter the name of the solution:
10. Reason(s) for registering. Please check all that apply.

AccreditationRegulatory RequirementSoftware ProviderLabeling or Relabeling ISBT 128Access to the Product Description Code DatabaseMPHO SupplierMPHO End UserOther
If other, please specify:
11. Signature of authorized person:

I request registration of the above-named facility by ICCBBA. I agree to the terms and conditions of the License Agreement and understand that an annual license fee (payable when invoiced) will be required to maintain this registration. I represent and warrant that I have full authority to bind my organization to the terms and conditions of the License Agreement.
Signature* Date*
Printed Name*
Position*
World Bank Classification
- If your facility is in a country classified as Upper-Middle Gross National Income per capita, your license fee will be reduced by 10%.
- If your facility is in a country classified as Lower-Middle Gross National Income per capita, your license fee will be reduced by 33% and the registration fee will be waived.
- If your facility is in a country classified as Low Gross National Income per capita, your license fee will be reduced by 66% and the registration fee will be waived..
Information on country classification is available from the World Bank at:
https://data.worldbank.org/
12. Payment Options:

We accept credit cards (Visa and Mastercard only), wire transfers and ACH payments. Please submit your completed registration form to us for review and we will reach out to you with an invoice with the appropriate amount due at the time of registration. Please do not send any payments before your registration form is submitted.

NO PURCHASE ORDERS

Credit Card (VISA or MasterCard only)

For credit card payments, we will email you your invoice. Once you receive the invoice, please visit our online payment portal at: https://www.ICCBBA.org/payment-portal/. No telephone orders accepted.

Bank Draft/Wire

Transfer appropriate amount to: Bank of America, NA
222 Broadway, New York, New York, 10038
Bank Number 053000196 BIC/SWIFT: BOFAUS3N

Payable to: ICCBBA, Account Number 000683127591

PART B:
Information from this form will be used to assign Facility Identification Numbers (FIN) and create entries in the official ICCBBA Facility Identification Number database that is maintained on the ICCBBA Website.

It is left to the discretion of the organization registering how many FINs are requested, and how they are assigned within the organization. The additional FIN section must be filled out for each FIN requested.

Complete the following section identifying the CONTACT LOCATION for the facility. This contact location will be associated with the Facility Identification Number in the ICCBBA database and should provide the information necessary to contact the facility if any questions arise about a product bearing the particular Facility Identification Number.

Note: Information provided to ICCBBA will be used for billing and registration purposes, and to assist ICCBBA in its operations – this may include periodic surveys or any other type of announcement. If you wish to opt -out of surveys or announcements, please contact us. To view our full privacy policy, visit the following URL: https://www.ICCBBA.org/privacy-policy
Full Legal Name of Facility Registering*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
Website
Telephone Country Code*
Telephone Number*
Fax
Fee for each additional FIN: $250

Note: If you require more than 4 additional FINs, please reach out to our office at registration@iccbba.org.
Additional FIN #1
Full Legal Name of Facility Registering
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Website
Telephone Country Code
Telephone Number
Fax
Additional FIN #2
Full Legal Name of Facility Registering
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Website
Telephone Country Code
Telephone Number
Fax
Additional FIN #3
Full Legal Name of Facility Registering
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Website
Telephone Country Code
Telephone Number
Fax
Additional FIN #4
Full Legal Name of Facility Registering
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Website
Telephone Country Code
Telephone Number
Fax
Should be Empty:

ICCBBA - APPLICATION FOR FACILITY REGISTRATION

7. Specify Registration type (CHECK ALL THAT APPLY) if multiple only one registration fee will apply.

Chain of Identity Identifiers:

Blood Collection Facility:

Transfusion Laboratory:

Serum Eye Drops Facility:

Cellular Therapy Facility:

Reproductive Tissues and/or Cell Facility:

Organ Transplant Facility:

Regenerative Medicine Facility:

Tissue – Non-Ocular Facility:

Tissue – Ocular Facility:

Human Milk Bank Facility:

HCT/P Medical Device Manufacturer:

Proficiency Testing Facility:

Fecal Microbiota Facility:

Registration Fee: Please see below for fees.

Additional FIN(s) Fee: $250.00

Plasma Fractionator or Further Processing Facilities

World Bank Classification

NO PURCHASE ORDERS

PART B:

Additional FIN #1

Additional FIN #2

Additional FIN #3

Additional FIN #4