Compliance Officer Form

Vermont Office of Attorney General

109 State Street
Montpelier, VT 05609-1001

Due Date: April 1, 2024

Section 1: Manufacturing Company

Name of Manufacturing Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Type of Manufacturing, (Check all that apply)

Pharmaceuticals

Biologics

Medical Devices

Phone Number

Website Address

Section II: Compliance Officer

Name of Individual Responsible for Compliance

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

E-Mail Address

Confirm email

Section III: Data Collection and Reporting, If different from Compliance Officer, check if same

Same as Compliance Officer

Name of Individual Responsible for Data Collection

Title of Individual Responsible for Compliance

Telephone

E-Mail Address

Confirm email

Section IV: Filing

Will Report 2023 Expenditures/Samples by April 1, 2024

No 2023 Expenditures/Samples to report

Do you intend to submit data that would have been (or was) submitted to the federal government under the Patient Protection and Affordable Care Act?

Yes

Section V: Declaration

I certify that the information stated by me in this disclosure is true and accurate to the best of my knowledge. I understand that providing false information or omission of information is unlawful.

Certify by typing your name

Submission Date

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.