FDA PRIOR NOTICE

Submitter
* Company Name				FDA Registration #
* Street Address				* City
* State                       * Country                       * Postal Code
* Phone				Fax
* E-mail				* Shipping Country
* Contact person First Name				* Last Name
Consignee/Importer
* Company Name				FDA Registration #
* Street Address				* City
* State                       * Country                       * Postal Code
* Phone				Fax
* E-mail
* Contact person First Name				* Last Name
Manufacturer/Grower (fill only if different from submitter)
* Company Name				* FDA Registration #
* Street Address				* City
* State                       * Country                       * Postal Code
* Phone				Fax
* Email
* Contact person First Name				* Last Name
Holding Facility - Required if this Prior Notice is Submitted Post Refusal
Warehouse Name				FDA Registration #
Street Address				City
State                       Postal Code                       Phone
Fax				Email
Contact person First Name				Last Name
Owner - owner of the article (please select )
Submitter                                Consignee                                       Manufacturer                                   Other
Shipper - shipper of the article (please select )
Submitter                           Manufacturer                                   Other
Carrier - By Air
Carrier Name				Flight Number
Air Bill Number				U.S. State of Entry
U.S. Airport of Entry				Arrival Date and Time
Carrier - By Sea
Carrier Name				Vessel Name
Bill of Lading Number				Voyage number
U.S. Port of Entry				Container Number
U.S. State of Entry				Arrival Date and Time
Product Description - Product 1
* Name & Description				FDA Product Code
Product Identifiers (for acidified & low acid canned foods)				* Base Unit (e.g. 1 Lb per Can)
* Estimated Quantity: (e.g 100 Cartons, 40 cans per Carton)
* Total Quantity: (e.g 4000 can, 4000 Lb)
* Packaging-Material, Shape, Process applied: (e.g Tin, cylindrical sterilized/ Pasteurized)
Product Description - Product 2
Name & Description				FDA Product Code
Product Identifiers: (for acidified & low acid canned foods)				Base Unit: (e.g 1 Lb per Can)
Estimated Quantity: (e.g 100 Cartons, 40 cans per Carton)
Total Quantity: (e.g 4000 can, 4000 Lb)
Packaging-Material, Shape, Process applied: (e.g Tin, cylindrical sterilized/ Pasteurized)
Product Description - Product 3
Name & Description				FDA Product Code
product Identifiers: (for acidified & low acid canned foods)				Base Unit: (e.g 1 Lb per Can)
Estimated Quantity: (e.g 100 Cartons, 40 cans per Carton)
Total Quantity: (e.g 4000 can, 4000 Lb)
Packaging-Material, Shape, Process applied: (e.g Tin, cylindrical sterilized/ Pasteurized)
Has any of the above product has been refused by any country?         Yes No
If Yes list the product and countries of refusal
By submitting the form you agree and warrant that the information stated above are accurate, truthful and current and authorize Liberty Management Group Ltd. to submit the prior notice information to the U.S. FDA
Submitter Name        Job Title        Submitter E-mail