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 $
Additional Facility Registration USD 100 / Facility $
Food Canning Establishment Registration Assistance USD 649 /
Establishment
$
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
To be completed by all food facilities. TYPE OF ACTIVITY CONDUCTED AT THE FACILITY
Check all types of operations that are performed at this facility
regarding the manufacturing/processing, packing or holding of food.
IF NONE OF THE MANDATORY
CATEGORIES BELOW APPLY,
SELECT BOX 37.
Ambient Food Storage Warehouse / Holding Facility Refrigerated Food Storage Warehouse / Holding Facility Frozen Food Storage Warehouse / Holding Facility Acidified Food Processor Low Acid Food Processor Interstate Conveyance Caterer Catering Point Contract Sterilizer Labeler Relabeler Manufacturer / Processor Packer / Repacker Salvage Operator (Reconditioner) Farm MixedType Facility Other Activity Conducted
1. ALCOHOLIC BEVERAGES
[21 CFR 170.3 (n) (2)]
2. BABY (INFANT AND
JUNIOR) FOOD PRODUCTS
Including Infant Formula
3. BAKERY PRODUCTS,
DOUGH MIXES, OR ICINGS
[21 CFR 170.3 (n) (1), (9)]
4. BEVERAGE BASES
[21 CFR 170.3 (n) (3), (35)]
5. CANDY WITHOUT CHOCOLATE,
CANDY SPECIALTIES
AND CHEWING GUM
[21 CFR 170.3 (n) (6), (9), (25), (38)]
6. CEREAL PREPARATIONS,
BREAKFAST FOODS, QUICK
COOKING / INSTANT CEREALS
[21 CFR 170.3 (n) (4)]
7. CHEESE AND CHEESE
PRODUCT CATEGORIES
[21 CFR 170.3 (n) (5)]
a. Soft, Ripened Cheese
b. Semi-Soft Cheese
c. Hard Cheese
d. Other Cheeses and
Cheese Products
8. CHOCOLATE AND
COCOA PRODUCTS
[21 CFR 170.3 (n) (3), (9), (38), (43)]
9. COFFEE AND TEA
[21 CFR 170.3 (n) (3), (7)]
10. COLOR ADDITIVES FOR FOODS
[21 CFR 170.3 (o) (4)]
11. DIETARY CONVENTIONAL
FOODS OR MEAL
REPLACEMENTS
(Includes Medical Foods)
[21 CFR 170.3 (n) (31)]
12. DIETARY SUPPLEMENT
CATEGORIES
a. Proteins, Amino Acids,
Fats and Lipid Substances
[21 CFR 170.3 (o) (20)]
b. Vitamins and Minerals
c. Animal By-Products and Extracts
d. Herbals and Botanicals
13. DRESSING AND CONDIMENTS
[21 CFR 170.3 (n) (8), (12)]
14. FISHERY / SEAFOOD PRODUCT
CATEGORIES [21 CFR 170.3 (n)
(13), (15), (39), (40)]
a. Fin Fish, Whole or Filet
b. Molluscan Shellfish
c. Other Shellfish
d. Ready to Eat (RTE) Fishery
Products
e. Processed and Other Fishery
Products
15. FOOD ADDITIVES, GENERALLY
RECOGNIZED AS SAFE (GRAS)
INGREDIENTS, OR OTHER
INGREDIENTS 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)]
16. FOOD SWEETENERS
(NUTRITIVE) [21 CFR 170.3 (n) (9)
(41), 21 CFR 170.3 (o) (21)]
17. FRUIT AND FRUIT PRODUCTS
[21 CFR 170.3 (n) (16), (27), (28),
(35), (43)]
a. Fresh Cut Produce
b. Raw Agricultural Commodities
c. Other Fruit and Fruit Products
18. FRUIT OR VEGETABLE
JUICE, PULP OR
CONCENTRATE PRODUCTS
[21 CFR 170.3 (n) (3), (16), (35)]
19. GELATIN, RENNET, PUDDING
MIXES, OR PIE FILLINGS
[21 CFR 170.3 (n) (22)]
20. ICE CREAM AND
RELATED PRODUCTS
[21 CFR 170.3 (n) (20), (21)]
21. IMITATION MILK PRODUCTS
[21 CFR 170.3 (n) (10)]
22. MACARONI OR
NOODLE PRODUCTS
[21 CFR 170.3 (n) (23)]
23. MEAT, MEAT PRODUCTS AND
POULTRY (FDA REGULATED)
[21 CFR 170.3 (n) (17), (18), (29),
(34), (39), (40)]
24. MILK, BUTTER, OR
DRIED MILK PRODUCTS
[21 CFR 170.3 (n) (12), (30), (31)]
25. MULTIPLE FOOD DINNERS,
GRAVIES, SAUCES
AND SPECIALTIES
[21 CFR 170.3 (n) (11) (14), (17),
(18), (23), (24), (29), (34), (40)]
26. NUTS AND EDIBLE SEED
PRODUCT CATEGORIES
[21 CFR 170.3 (n) (26), (32)]
a. Nut and Nut Products
b. Edible Seed and Edible Seed
Products
27. PREPARED SALAD PRODUCTS
[21 CFR 170.3 (n) (11), (17), (18),
(22), (29), (34), (35)]
28. SHELL EGG AND EGG PRODUCT
CATEGORIES [21 CFR 170.3 (n)
(11), (14)]
a. Chicken Egg and Egg Products
b. Other Eggs and Egg Products
29. SNACK FOOD ITEMS (FLOUR,
MEAL OR VEGETABLE BASE)
[21 CFR 170.3 (n) (37)]
30. SPICES, FLAVORS, AND SALTS
[21 CFR 170.3 (n) (26)]
31. SOUPS
[21 CFR 170.3 (n) (39), (40)]
32. SOFT DRINKS AND WATERS
[21 CFR 170.3 (n) (3), (35)]
33. VEGETABLE AND VEGETABLE
PRODUCT CATEGORIES
[21 CFR 170.3 (n) (19), (36)]
a. Fresh Cut Products
b. Raw Agricultural Commodities
c. Other Vegetable and Vegetable
Products
34. VEGETABLE OILS (INCLUDES
OLIVE OIL) [21 CFR 170.3 (n) (12)]
35. VEGETABLE PROTEIN
PRODUCTS (SIMULATED
MEATS) [21 CFR 170.3 (n) (33)]
36. WHOLE GRAINS, MILLER
GRAIN PRODUCTS (FLOURS),
OR STARCH
[21 CFR 170.3 (n) (1), (23)]
37. IF NONE OF THE ABOVE FOOD
CATEGORIES APPLY, THEN
PRINT THE APPLICABLE FOOD
CATEGORY OR CATEGORIES
(THAT DOES NOT OR DO NOT
APPEAR ABOVE).
Section 9b – GENERAL PRODUCT CATEGORIES - FOOD FOR ANIMAL CONSUMPTION; and
TYPE OF ACTIVITY CONDUCTED AT THE FACILITY
To be completed by all food
facilities.
TYPE OF ACTIVITY CONDUCTED AT THE FACILITY
Check all types of operations that are performed at this facility regarding
the manufacturing/processing, packing or holding of food.
IF NONE OF THE MANDATORY
CATEGORIES BELOW APPLY,
SELECT BOX 33.
Animal food
manufacturer
/ Processor
Animal Food Warehouse / Holding Facility
(e.g., storage facilities, including
storage tanks, grain elevators)
Acidified Food
Processor
Low
Acid Food
Processor
Contract
Sterilizer
Packer /
Repacker
Labeler /
Relabeler
Salvage
Operator
(Reconditioner)
Farm Mixed-Type Facility Other
Activity
1. GRAIN OR GRAIN PRODUCTS (I.E.,
BARLEY, GRAIN SORGHUMS, MAIZE,
OAT, RICE, RYE, WHEAT, OTHER
GRAINS OR GRAIN PRODUCTS)
2. OILSEED OR OILSEED PRODUCTS
(I.E., COTTONSEED, SOYBEANS,
OTHER OILSEEDS OR OILSEED
PRODUCTS)
3. ALFALFA PRODUCTS OR
LESPEDEZA PRODUCTS
4. AMINO ACIDS OR
RELATED PRODUCTS
5. ANIMAL PROTEIN PRODUCTS
6. BOTANICALS AND HERBS
7. BREWER PRODUCTS
8.CHEMICAL PRESERVATIVES
9. CITRUS PRODUCTS
10. DIRECT FED MICROBIALS
11. DISTILLERY PRODUCTS
12. ENZYMES
13. FATS OR OILS
14. FERMENTATION PRODUCTS
15. FORAGE PRODUCTS
16. HUMAN FOOD BY-PRODUCTS NOT OTHERWISE LISTED
17. MARINE PRODUCTS
18. MILK PRODUCTS
19. MINERALS OR MINERAL PRODUCTS
20. MISCELLANEOUS OR SPECIAL
PURPOSE PRODUCTS
21. MOLASSES OR MOLASSESS
PRODUCTS
22. NON-PROTEIN NITROGEN
PRODUCTS
23. PEANUT PRODUCTS
24. PROCESSED ANIMAL WASTE
PRODUCTS
25. SCREENINGS
26. TECHNICAL ADDITIVES
27. VITAMINS OR VITAMIN PRODUCTS
28. YEAST PRODUCTS
29.MIXED FEED (E.G., POULTRY,
LIVESTOCK, EQUINE)
30. PET FOOD
31. PET TREATS OR PET CHEWS
32. PET NUTRITIONAL SUPPLEMENTS
(E.G., VITAMINS, MINERALS)
33. IF NONE OF THE ABOVE FOOD
CATEGORIES APPLY, THEN PRINT
THE APPLICABLE FOOD CATEGORY
OR CATEGORIES (THAT DOES NOT
OR DO NOT APPEAR ABOVE).
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

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.

Submitter Name    Job Title    Submitter E-mail

Alternate E-mail