FDA Food Facility Registration Form

Description of Service and Cost

Services	Fees	Number of services	Total Fees
Food Facility Registration, US Agent Service and Certificate of Registration	USD 349 / Annually	Please Enter	$
Additional Facility Registration	USD 100 / Facility	Please Enter	$
Food Canning Establishment Registration Assistance	USD 649 / Establishment	Please Enter	$
Total			$

Section 1 – TYPE OF REGISTRATION

DOMESTIC REGISTRATION

FOREIGN REGISTRATION

INITIAL REGISTRATION

UPDATE OF REGISTRATION INFORMATION

BIENNIAL REGISTRATION RENEWAL

RE-REGISTRATION DUE TO INCOMPLETE BIENNIAL RENEWAL

If update or biennial registration renewal, provide
the Facility Registration Number and PIN

If Re-Registration due to Incomplete biennial renewal, please provide the Registration number.

Facility Registration Number		PIN

Are you a fishing vessel engaged in processing (21 CFR 1.226(f))? Yes No

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

Company Type

If Other Enter:

Street Address Line 1

Street Address Line 2

City

State (If applicable; if not, skip to Province/Territory)

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

E-Mail Address

DUNS Number:
(Mandatory)

Section 3 – PREFERRED MAILING ADDRESS INFORMATION
Complete this section only if different from Section 2 Facility Name/Address Information (OPTIONAL)

Name

Street Address Line 1

Street Address Line 2

City

State (If applicable; if not, skip to Province/Territory)

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

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 Section 3

Name of Parent Company

Street Address Line 1

Street Address Line 2

City

State (If applicable; if not, skip to Province/Territory)

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

E-Mail Address

Section 5 – FACILITY EMERGENCY CONTACT INFORMATION

Individual Name

Job Title

E-Mail Address

Emergency Contact Phone Number (Include Area/Country Code)

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").

Alternative Trade Name #1

Alternative Trade Name #2

Alternative Trade Name #3

Alternative Trade Name #4

Section 7 – UNITED STATES AGENT - (For Foreign Food Facilities)
Liberty Management Group Ltd. will be the appointed U.S. Agent for this Facility.

Section 8 – SEASONAL FACILITY DATES OF OPERATION (OPTIONAL)
Optional - Give the approximate dates that your facility is open for business, if its operations are on a seasonal basis.

Dates of Operation (Optional; mm/dd/yyyy)

Section 9 – GENERAL PRODUCT CATEGORIES - Human/Animal/Both

Food for Human Consumption Food for Animal Consumption

Section 9a – GENERAL PRODUCT CATEGORIES - FOOD FOR HUMAN CONSUMPTION; and
TYPE OF ACTIVITY CONDUCTED AT THE FACILITY

Section 9b – GENERAL PRODUCT CATEGORIES - FOOD FOR ANIMAL CONSUMPTION; and
TYPE OF ACTIVITY CONDUCTED AT THE FACILITY

Section 10 – OWNER OR OPERATOR INFORMATION

Name of Entity or Individual Who Is the Owner or Operator.

Provide the following information, if different from all other sections on the form. If the information is the same as another section of the form, check which section.
Section 2 Section 3 Section 4

Street Address, Line 1

Street Address, Line 2

City

State (If applicable; if not, skip to Province/Territory)

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

E-Mail Address

Section 11 – INSPECTION STATEMENT

FDA will be permitted to inspect the facility at the time and in the manner permitted by the Federal Food, Drug, and Cosmetic Act.

Section 12 – 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 true 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, fictitious, or fraudulent statement to the U.S. Government is subject to criminal penalties.

I agree to the above Terms and Conditions

Submitter Name Job Title Submitter E-mail

Alternate E-mail

FDA Food Facility Registration Form

Register with FDA