The following Form are for information only, so you can view the data required by the FDA. If you would like to Officially Register, click on any of the "register buttons" located on top, on the right side and bottom of the page or click here.

Date: (MONTH/DAY/YEAR)

Section 1 - TYPE OF REGISTRATION
Facility Location

  ARE YOU THE NEW OWNER OF A PREVIOUSLY REGISTERED FACILITY?

YES / NO
If "yes", provide the following information, if known
Previous owner's name
Previous owner's registration number
 

Section 2 - FACILITY NAME / ADDRESS INFORMATION
FACILITY NAME:
FACILITY STREET ADDRESS:
CITY STATE:
ZIP CODE (POSTAL CODE): PROVINCE/TERRITORY:
COUNTRY:       PHONE NUMBER(if a foreign facility, include Area & Country Codes):
FAX NUMBER (if available; if a foreign facility, include Area & Country Codes): E-MAIL ADDRESS (if available):

Section 3 - OPTIONAL: PREFERRED MAILING ADDRESS INFORMATION
(only complete this section if different from Section 2, Facility Name/Address Information)
NAME:
ADDRESS:
CITY: STATE:
ZIP CODE (POSTAL CODE): PROVINCE/TERRITORY:
COUNTRY:   PHONE NUMBER (if a foreign facility, include Area & Country Codes):
FAX NUMBER (if a foreign facility, include Area & Country Codes): E-MAIL ADDRESS:

Section 4 - PARENT COMPANY NAME / ADDRESS INFORMATION(IF APPLICABLE AND IF DIFFERENT FROM SECTIONS 2 and 3). IF INFORMATION IS THE SAME AS ANOTHER SECTION, CHECK WHICH SECTION:

Section 2 - Facility Address Information or
Section 3 - Preferred Mailing Address Information

 
NAME OF PARENT COMPANY:
STREET ADDRESS OF PARENT COMPANY:
CITY: STATE:
ZIP CODE (POSTAL CODE): PROVINCE/TERRITORY
COUNTRY:     PHONE NUMBER (if a foreign facility, include Area & Country Codes):
FAX NUMBER (if a foreign facility, include Area & Country Codes): E-MAIL ADDRESS (If available):

Section 5 - FACILITY EMERGENCY CONTACT INFORMATION(OPTIONAL FOR FOREIGN FACILITIES; FDA WILL USE YOUR U.S. AGENT AS YOUR EMERGENCY CONTACT UNLESS YOU CHOOSE TO DESIGNATE A DIFFERENT CONTACT HERE)
INDIVIDUAL'S NAME:
TITLE: OFFICE PHONE(If a foreign facility, include Area & Country Codes):
HOME PHONE (if a foreign facility, include Area & Country Codes):

CELL PHONE (if a foreign facility, include Area & Country Codes):

E-MAIL ADDRESS(If available):

Section 6 - TRADE NAMES (IF THIS FACILITY USES TRADE NAMES OTHER THAN THAT LISTED IN SECTION 2
ABOVE. LIST THEM BELOW (E.G.. “ALSO DOING BUSINESS AS.” “FACILITY ALSO KNOWN AS”):
ALTERNATE TRADE NAME #1:
ALTERNATE TRADE NAME #2:
ALTERNATE TRADE NAME #3:
ALTERNATE TRADE NAME #4:

Section 7 - UNITED STATES AGENT (TO BE COMPLETED BY FACILITIES LOCATED OUTSIDE ANY STATE
OR TERRITORY OF THE UNITED STATES, THE DISTRICT OF COLUMBIA, OR THE COMMONWEALTH OF PUERTO RICO.)
NAME OF UNITED STATES AGENT: This Section will be filled in by Global Trading Hub
TITLE:
ADDRESS:
CITY: STATE:
ZIP CODE: COUNTRY:   
PHONE NUMBER (include Area code):
FAX NUMBER (if available; indude Area Code):
E-MAIL ADDRESS (if available):

Section 8 - OPTIONAL: SEASONAL FACILITY DATES OF OPERATION
(GIVE THE APPROXIMATE DATES THAT YOUR FACILITY IS OPEN FOR BUSINESS, IF ITS OPERATIONS
ARE ON A SEASONAL BASIS)
DATES OF OPERATION:

Section 9 - OPTIONAL: ESTABLISHMENT TYPES
(CHECK ALL TYPES OF OPERATIONS THAT ARE PERFORMED AT THIS FACILITY REGARDING THE MANUFACTURING, PROCESSING, PACKING OR HOLDING OF FOOD)

Warehouse / Holding Facility (e.g., storage facilities, induding storage tanks, grain elevators)
Acidified / Low Acid Food Processor Labeler / Relabeler
Interstate Conveyance Caterer/Catering Point Manufacturer / Processor
Molluscan Shellfish Establishment Repacker /Packer
Commissary Salvage Operator (Reconditioner)
Contract Sterilizer Animal food manufacturer / processor / holder

Section 10 - OPTIONAL: IF YOUR FACILITY IS SOLELY A WAREHOUSE / HOLDING FACILITY,
COMPLETE THIS SECTION; ALL OTHER FACILITIES, COMPLETE SECTION 11 (human or
animal product categories) INSTEAD OF THIS SECTION.
Ambient Storage ( including heated storage) Refrigerated Storage Frozen Storage

Section 11a
To be completed by all food facilities. Please see instructions for further examples. IF NONE OF THE MANDATORY CATEGORIES BELOW APPLY, SELECT BOX 37.

  1. ALCOHOLIC BEVERAGES
[21 CFR 170.3 (n) (2)]		   18. GELATIN, RENNET, PUDDING MIXES, OR PIE FILLINGS [21 CFR 170.3 (n) (22)]
  2. BABY (INFANT AND JUNIOR) FOOD PRODUCTS Including Infant Formula (Optional Selection)   19. ICE CREAM AND RELATED PRODUCTS
[21 CFR 170.3 (n) (20), (21)]
  3. BAKERY PRODUCTS, DOUGH MIXES, OR ICINGS
[21 CFR 170.3 (n)(1), (9)] 		  20. IMITATION MILK PRODUCTS
[21 CFR 170.3 (n) (l0)]
 

4. BEVERAGE BASES
[21 CFR 170.3 (n) (3) (16). (35)]

   21. MACARONI OR NOODLE PRODUCTS
[21 CFR 170.3 (n) (23)]
  5. CANDY WITHOUT CHOCOLATE, CANDY /
SPECIALITIES & CHEWING GUM
[21 CFR 170.3 (n) (6), (9), (25), (38)]		   22. MEAT, MEAT PRODUCTS AND POULTRY
(FDA REGULATED)
(21 CFR 170.3 (n) (17), (18), (29), (34). (39),
(40)]
  6. CEREAL PREPARATIONS, BREAKFAST FOODS, QUICK COOKING/INSTANT CEREALS
[ 21 CFR 170.3 (n) (4)]		   23. MILK, BUTTER, OR DRIED MILK PRODUCTS
[21 CFR 170.3 (n) (12). (30). (31)]
  7. CHEESE AND CHEESE PRODUCTS
[21 CFR 170.3 (n) (5)]		   24. MULTIPLE FOOD DINNERS, GRAVIES,
SAUCES AND SPECIALTIES [21 CFR 170.3 (n) (11). (14),
(17). (18). (23). (24). (29). (34), (40)]
  8. CHOCOLATE AND COCOA PRODUCTS
[21 CFR 170.3 (n) (3), (9), (38), (43)]		   25. NUT AND EDIBLE SEED PRODUCTS
[21 CFR 170.3 (n) (26) (32)]
  9. COFFEE AND TEA
[21 CFR 170.3 (n) (3), (7)]		   26. PREPARED SALAD PRODUCTS
[21 CFR 170.3 (n) (11), (17), (18), (22), (29), (34), (35)]
  10. COLOR ADDITIVES FOR FOODS
[21 CFR 170.3 (o) (4)]		   27. SHELL EGG AND EGG PRODUCTS
[21 CFR 170.3 (n) (ll), (14)]
  11. DIETARY CONVENTIONAL FOODS OR MEAL
REPLACEMENTS (indudes Medical Foods)
[21 CFR 170.3 (n ) (31)]		   28. SNACK FOOD ITEMS (FLOUR, MEAL OR VEGETABLE BASE) [21 CFR 170.3 (n) (37)]
 

12. DIETARY SUPPLEMENTS

  29. SPICES, FLAVORS, AND SALTS
[21 CFR 170.3 (n) (26)]
  Proteins, Amino Acids, Fats and Lipid Substances
[21 CFR 170.3 (0) (20)]		   30. SOUPS
[21 CFR 170.3 (n) (39). (40)]
  Vitamins and Minerals [21 CFR 170.3 (0) (20)]   31. SOFT DRINKS AND WATERS
[21 CFR 170.3 (n) (3), (35)]
  Animal By-Products and Extracts (Optional
Selection)		   32. VEGETABLES AND VEGETABLE PRODUCTS
[21 CFR 170.3 (n) (19). (36)]
  Herbals and Botanicals (Optional Selection)   33. VEGETABLE OILS (INCLUDES OLIVE OIL)
[21 CFR 170.3 (n) (12)]
  13. DRESSINGS AND CONDIMENTS
[21 CFR 170.3 (n) (8). (12)]		   34. VEGETABLE PROTEIN PRODUCTS (SIMULATED MEATS)
[ 21 CFR 170.3 (n) (33)]
  14. FISHERY/SEAFOOD PRODUCTS
[21 CFR 170.3 (n) (13). (15). (39), (40)]		   35. WHOLE GRAINS, MILLER GRAIN PRODUCTS (FLOURS), OR STARCH
[21 CFR 170.3 (n) (l), (23)]
  15. FOOD ADDITIVES, GENERALLY RECOGNIZED AS SAFE (GRAS) INGREDIENTS, OR OTHER INdREDlENTS USED FOR PROCESSING
[21 CFR 170.3 (n) (42); 21 CFR 170.3 (o) (1),
(2), (3), (5),(6),(7),(8), (9), (10), (11),(12), (13),
(14),(15),(16),(17),(18),(19),(22), (23), (24),
(25), (26), (27), (28), (29), (30) (31), (32) 		  36. MOST/ALL HUMAN FOOD PRODUCT CATEGORIES(Optional Selection)
  16. FOOD SWEETENERS (NUTRITIVE)
[21 CFR 170.3 (n) (9), (41), 21 CFR 170.3 (0)(21)]		   37. NONE OF THE ABOVE MANDATORY CATEGORIES
  17. FRUITS AND FRUIT PRODUCTS
[21 CFR 170.3 (n) (16), (27), (28). (35). (43)] 		   

Section 11b - OPTIONAL GENERAL PRODUCT CATEGORIES - FOOD FOR ANIMAL
CONSUMPTION
  1. GRAIN PRODUCTS (E.G., BARLEY, GRAIN SORGHUMS, MAIZE, OAT, RICE. RYE AND
WHEAT)		   18. NON-PROTEIN NITROGEN PRODUCTS
  2. OILSEED PRODUCTS (E.G., COTTONSEED. SOYBEANS, OTHER OIL SEEDS)   19. PEANUT PRODUCTS
  3. ALFALFA AND LESPEDEZA PRODUCTS   20. RECYCLED ANIMAL WASTE PRODUCTS
  4. AMINO ACIDS   21. SCREENINGS
  5. ANIMAL-DERIVED PRODUCTS   22. VITAMINS
  6. BREWER PRODUCTS   23. YEAST PRODUCTS
  7. CHEMICAL PRESERVATIVES   24. MIXED FEED (POULTRY, LIVESTOCK. AND EQUINE)
  8. CITRUS PRODUCTS   25. PET FOOD
  9. DISTILLERY PRODUCTS   26. MOST/ALL ANIMAL FOOD PRODUCT CATEGORIES
  10. ENZYMES    
  11. FATS AND OILS    
  12. FERMENTATION PRODUCTS    
  13. MARINE PRODUCTS    
  14. MILK PRODUCTS    
  15. MINERALS    
  16. MISCELLANEOUS AND SPECIAL PURPOSE
PRODUCTS		    
  17. MOLASSES    
 
Section 12
 

*NAME OF ENTITY OR INDIVIDUAL WHO IS THE OWNER,OPERATOR,OR AGENT IN CHARGE

PROVIDE THE FOLLOWING INFORMATION, IF DIFFERENT FROM ALL OTHER SECTIONS ON THE FORM. IF INFORMATION IS THE SAME AS ANOTHER SECTION OF THE FORM, CHECK WHICH SECTION:

Section 2 - Facility Address Information
Section 3 - Preferred Mailing Address Information
Section 4 - Parent Company Address Information

Section 7 - US Agent Address Information
 
STREET ADDRESS
CITY
COUNTRY:
STATE/PROVINCE/TERRITORY
ZIP CODE (POSTAL CODE)
Numbers only. No spaces, dashes or parentheses. Country Code not required for US phone numbers.
PHONE
FAX NUMBER
 
E-MAIL ADDRESS

Section 13 - CERTIFICATION STATEMENT
The owner, operator, or agent in charge of the facility, or an individual authorized by the owner, operator, or agent in charge of the facility, must submit this form. By submitting this form to FDA, or by authorizing an individual to submit this form to FDA, the owner, operator, or agent in charge of the facility certifies that the above information is true and accurate. An individual (other than the owner, operator or agent in charge of the facility) who submits the form to the FDA also certifies that the above information submitted is ture and accurate and that he/she is authorized to submit the registration on the facility's behalf. An individual authorized by the owner, operator, or agent in charge must below identify by name the individual who authorized submission of the registration. Under 18 U.S.C 1001, anyone who makes a materially false, ficticious, or fraudulent statement to the U.S. Government is subject to criminal penalties.

PRINT NAME OF PERSON SUBMITTING THE REGISTRATION FORM:

CHECK ONE BOX
A.OWNER, OPERATOR, OR AGENT IN CHARGE (STOP HERE, FORM IS COMPLETED)
B.INDIVIDUAL AUTHORIZED TO SUBMIT THE REGISTRATION (FILL IN ADDRESS BELOW)
IF YOU CHECKED BOX B ABOVE, INDICATE WHO AUTHORIZED YOU TO SUBMIT THE REGISTRATION:
OWNER, OPERATOR, OR AGENT IN CHARGE (STOP HERE, FORM IS COMPLETED)
NAME OF INDIVIDUAL WHO AUTHORIZED REGISTRATION ON BEHALF OF OWNER,OPERATOR, OR AGENT IN CHARGE (FILL IN ADDRESS BELOW)

 

These fields are required only if the section applies
ADDRESS INFORMATION FOR THE AUTHORIZING INDIVIDUAL: 
 
AUTHORIZING INDIVIDUAL STREET ADDRESS
CITY
COUNTRY
STATE/PROVINCE/TERRITORY
ZIP CODE (POSTAL CODE)
PHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS

 

If you have been referred by a person or company, please enter the Name and Associate Number here:
 Name:
Associate Number

 


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