(Date)
Office of the Secretary, Consumer Product Safety Commission, Room 502, 4330 East West Highway, Bethesda, MD. Mailing address: Office of the Secretary, Consumer Product Safety Commission, Washington, DC 20207.
NOTICE OF PARTICIPATION
(Title of Regulation)
Docket No. _______________________________
Please enter the participation of:
(Name) _______________________________
(Street address) _______________________________
(City, State, and Zip Code) _______________________________
_______________________________
(Telephone number) _______________________________
Service on the above will be accepted by:
(Name) _______________________________
(City, State, and Zip Code) _______________________________
_______________________________
(Telephone number) _______________________________
The following statements are made as part of this notice of participation:
(Signed)_______________________________
16 C.F.R. §1502.16