submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that submitting false information or statements is a violation of law.” Responsible Entity Signature ____________________________________ Date__________________ [Insert Full Name] Responsible Entity Signature ____________________________________ Date__________________ [Insert Full Name] 2.0 Responsible Entity and Supply Chain Information [Include the following in this section: The name, contact information, headquarters location of manufacturer(s) and importer(s), if applicable; If the Preliminary AA Report is a consortium, the name and contact information of each participant; The name and contact information for any person(s) identified on the Priority Product label as the manufacturer, importer, or distributor; The name and contact information for all person(s) in California other than the final purchaser or lessee to whom the manufacturer or importer directly sold the Priority Product within the prior 12 months; and The identification and location of the manufacturer’s and/or importer’s retail sales outlets where the manufacturer and/or importer sold, supplied, or offered for sale the Priority Product in California.] Manufacturer(s) and Importer(s): First Name Last Name Company Business Type [Manufacturer, Importer, etc.] Email
submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that submitting false information or statements is a violation of law.” Responsible Entity Signature ____________________________________ Date__________________ [Insert Full Name] Responsible Entity Signature ____________________________________ Date__________________ [Insert Full Name] 2.0 Responsible Entity and Supply Chain Information [Include the following in this section: The name, contact information, headquarters location of manufacturer(s) and importer(s), if applicable; If the Preliminary AA Report is a consortium, the name and contact information of each participant; The name and contact information for any person(s) identified on the Priority Product label as the manufacturer, importer, or distributor; The name and contact information for all person(s) in California other than the final purchaser or lessee to whom the manufacturer or importer directly sold the Priority Product within the prior 12 months; and The identification and location of the manufacturer’s and/or importer’s retail sales outlets where the manufacturer and/or importer sold, supplied, or offered for sale the Priority Product in California.] Manufacturer(s) and Importer(s): First Name Last Name Company Business Type [Manufacturer, Importer, etc.] Email
Preliminary-AA-Report-Template-Ver-1-0_July-2018.docx