AC-HSS Registration for
Membership
26925 Reiling Ave., Monroe, OR 97456, USA Phone: 1-541-847-1072 Fax: 1-866-600-9008 www.AC-HCC.org
Name of Contact
Person:
Title:
Company Name:
Address:
City:
State/Zip:
*SMS Available?
Telephone:
Yes
No
Facsimile:
Office
Cell*
Email:
“Opt-In” for Email & News Releases?
Website:
DUNS Number:
Please provide social media accounts
names for updates and member news:
Yes
LinkedIn
Twitter
Other:
Were you referred to AC-HSS by
someone? If so let us know:
Company Information:
Total number of employees (including permanent, part time, contract,
temporary, in site extensions and in remote functions employees):
Total number of employees on site, related to the AC-HSS business
(including permanent, part time, contract, and temporary employees):
Total number of employees in remote locations, related to the AC-HSS
business (including permanent, part time, contract, and temporary
employees):
Total number of employees in site extensions, related to the AC-HSS
business (including permanent, part time, contract, and temporary
employees):
Select your activity(s) in the AC-HSS business:
 Design and Development
 Maintenance
 Manufacturing
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AC-HSS Registration for
Membership
26925 Reiling Ave., Monroe, OR 97456, USA Phone: 1-541-847-1072 Fax: 1-866-600-9008 www.AC-HCC.org
Company already certified for:
Certification Body/Certificate Number:
 AS9100
 AS9120
 ISO 9001
 ISO 13485
 TL 9000
 TS 16949
Choose the Certification Body
to be linked with your
company:
Choose an item.
Please describe your interest and projected involvement in AC-HCC:
Please provide a detailed description of your company/product(s).
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Please provide a biography and contact information for the AC-HSS website membership page.
Annual Membership Dues:
OEM annual income is based on all reported income(s) from the sale of all goods and services from affiliates, related companies
and/or subsidiaries worldwide.
Original Equipment Manufacturers – Products
(OEM-Products):
Original Equipment Manufacturers – Components
(OEM-Components):
Retail Outlets:
Choose an item.
Distributors:
Choose an item.
Contractor Manufacturers:
Choose an item.
Certification Body (CB):
Choose an item.
Choose an item.
Choose an item.
Defined as an entity providing Hazardous Substance Process
Management Certification in accordance with an IAF Signatory
Accreditation Body’s established Accreditation Rules based on
International Standards and/or the IEC IECQ QC 080000
Specification.
Test Laboratory (NRTL):
Choose an item.
Defined as an entity providing chemical testing in accordance
with ILAC or equivalent Accreditation Rules based on National
and International Standards.
Law Firms:
Choose an item.
Consultants & Consulting Firms:
Choose an item.
Training Firms:
Choose an item.
Government Officials/Employees:
Choose an item.
Non Profit Organizations:
Choose an item.
Individuals:
Choose an item.
Complete and send this application form with a PHOTO by email to Ms. Christina Clark at [email protected] or
by regular post to 26925 Reiling Ave, Monroe, OR 97456 USA.
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