USFDA Food Facility Registration Application Form
Section 1 - TYPE OF REGISTRATION
 
         DOMESTIC REGISTRATION          FOREIGN REGISTRATION
         INITIAL REGISTRATION                      UPDATE OF REGISTRATION INFORMATION                                BIENNIAL REGISTRATION RENEWAL
  If update or biennial registration renewal, provide
the Facility Registration Number and PIN
 
Facility Registration Number   PIN
 
  For update of registration information: Check all that apply and further identify changes in the applicable sections United States Agent Change - Foreign facilities only
Facility Name Change Seasonal Facility Dates of Operation Change
Facility Address Change Type of Activity Change
Preferred Mailing Address Change Type of Storage Change
Parent Company Change Human Food Product Category Change
Emergency Contact Change Animal Food Product Category Change
Trade Name Change Operator or Agent in Charge Change
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  
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 - YPE OF STORAGE (for facilities that are primarily holders) (OPTIONAL)
 
     Ambient Storage (neither frozen nor refrigerated)                                         Refrigerated Storage                                       Frozen Storage
Section 10a - GENERAL PRODUCT CATEGORIES - FOOD FOR HUMAN CONSUMPTION; and
TYPE OF ACTIVITY CONDUCTED AT THE FACILITY (OPTIONAL)
 
To be completed by all food facilities. TYPE OF ACTIVITY CONDUCTED AT THE FACILITY
Optional - 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 39.
Warehouse /
Holding Facility
(e.g., storage
facilities,
including
storage tanks,
grain elevators)
Acidified /
Low Acid
Food
Processor
Interstate
Conveyance
Caterer /
Catering
Point
Molluscan
Shellfish
Establishment
Commissary Contract
Sterilizer
Labeler /
Relabeler
Manufacturer
/ Processor
Repacker
/ Packer
Salvage
Operator
(Reconditioner)
1. ACIDIFIED FOODS
(AF) [21 CFR 114.3(b)]
2. ALCOHOLIC BEVERAGES
[21 CFR 170.3 (n) (2)]
3. BABY (INFANT AND
JUNIOR) FOOD PRODUCTS
Including Infant Formula
4. BAKERY PRODUCTS,
DOUGH MIXES, OR ICINGS
[21 CFR 170.3 (n) (1), (9)]
5. BEVERAGE BASES
[21 CFR 170.3 (n) (3), (35)]
6. CANDY WITHOUT CHOCOLATE,
CANDY SPECIALTIES
AND CHEWING GUM
[21 CFR 170.3 (n) (6), (9), (25), (38)]
7. CEREAL PREPARATIONS,
BREAKFAST FOODS, QUICK
COOKING / INSTANT CEREALS
[21 CFR 170.3 (n) (4)]
8. 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
9. CHOCOLATE AND
COCOA PRODUCTS
[21 CFR 170.3 (n) (3), (9), (38), (43)]
10. COFFEE AND TEA
[21 CFR 170.3 (n) (3), (7)]
11. COLOR ADDITIVES FOR FOODS
[21 CFR 170.3 (o) (4)]
12. DIETARY CONVENTIONAL
FOODS OR MEAL
REPLACEMENTS
(Includes Medical Foods)
[21 CFR 170.3 (n) (31)]
13. 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
14. DRESSING AND CONDIMENTS
[21 CFR 170.3 (n) (8), (12)]
15. FISHERY / SEAFOOD PRODUCT
CATEGORIES [21 CFR 170.3 (n)
(13), (15), (39), (40)]
a. Fin Fish, Whole or Filet
b. Shellfish
c. Ready to Eat (RTE) Fishery
Products
d. Processed and Other Fishery
Products
16. 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)]
17. FOOD SWEETENERS
(NUTRITIVE) [21 CFR 170.3 (n) (9)
(41), 21 CFR 170.3 (o) (21)]
18. 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
19. FRUIT OR VEGETABLE
JUICE, PULP OR
CONCENTRATE PRODUCTS
[21 CFR 170.3 (n) (3), (16), (35)]
20. GELATIN, RENNET, PUDDING
MIXES, OR PIE FILLINGS
[21 CFR 170.3 (n) (22)]
21. ICE CREAM AND
RELATED PRODUCTS
[21 CFR 170.3 (n) (20), (21)]
22. IMITATION MILK PRODUCTS
[21 CFR 170.3 (n) (10)]
23. LOW ACID CANNED
FOOD (LACF) PRODUCTS
[21 CFR 113.3(n)]
24. MACARONI OR
NOODLE PRODUCTS
[21 CFR 170.3 (n) (23)]
25. MEAT, MEAT PRODUCTS AND
POULTRY (FDA REGULATED)
[21 CFR 170.3 (n) (17), (18), (29),
(34), (39), (40)]
26. MILK, BUTTER, OR
DRIED MILK PRODUCTS
[21 CFR 170.3 (n) (12), (30), (31)]
27. MULTIPLE FOOD DINNERS,
GRAVIES, SAUCES
AND SPECIALTIES
[21 CFR 170.3 (n) (11) (14), (17),
(18), (23), (24), (29), (34), (40)]
28. 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
29. PREPARED SALAD PRODUCTS
[21 CFR 170.3 (n) (11), (17), (18),
(22), (29), (34), (35)]
30. 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
31. SNACK FOOD ITEMS (FLOUR,
MEAL OR VEGETABLE BASE)
[21 CFR 170.3 (n) (37)]
32. SPICES, FLAVORS, AND SALTS
[21 CFR 170.3 (n) (26)]
33. SOUPS
[21 CFR 170.3 (n) (39), (40)]
34. SOFT DRINKS AND WATERS
[21 CFR 170.3 (n) (3), (35)]
35. 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
36. VEGETABLE OILS (INCLUDES
OLIVE OIL) [21 CFR 170.3 (n) (12)]
37. VEGETABLE PROTEIN
PRODUCTS (SIMULATED
MEATS) [21 CFR 170.3 (n) (33)]
38. WHOLE GRAINS, MILLER
GRAIN PRODUCTS (FLOURS),
OR STARCH
[21 CFR 170.3 (n) (1), (23)]
39. 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 10b - GENERAL PRODUCT CATEGORIES - FOOD FOR ANIMAL CONSUMPTION; and
TYPE OF ACTIVITY CONDUCTED AT THE FACILITY (OPTIONAL)
 
To be completed by all food
facilities.
TYPE OF ACTIVITY CONDUCTED AT THE FACILITY
Optional - 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 28.
Animal food
manufacturer
/ Processor
Warehouse / Holding Facility
(e.g., storage facilities, including
storage tanks, grain elevators)
Acidified / Low
Acid Food
Processor
Contract
Sterilizer
Packer /
Repacker
Labeler /
Relabeler
Salvage
Operator
(Reconditioner)
Other
Activity
Conducted
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-DERIVED PRODUCTS
6. BREWER PRODUCTS
7.CHEMICAL PRESERVATIVES
8. CITRUS PRODUCTS
9. DISTILLERY PRODUCTS
10. ENZYMES
11. FATS OR OILS
12. FERMENTATION PRODUCTS
13. MARINE PRODUCTS
14. MILK PRODUCTS
15. MINERALS OR MINERAL PRODUCTS
16. MISCELLANEOUS OR SPECIAL
PURPOSE PRODUCTS
17. MOLASSES OR MOLASSESS
PRODUCTS
18. NON-PROTEIN NITROGEN
PRODUCTS
19. PEANUT PRODUCTS
20. RECYCLED ANIMAL WASTE
PRODUCTS
21. SCREENINGS
22. VITAMINS OR VITAMIN PRODUCTS
23. YEAST PRODUCTS
24.MIXED FEED (E.G., POULTRY,
LIVESTOCK, EQUINE)
25. PET FOOD
26. PET TREATS OR PET CHEWS
27. PET NUTRITIONAL SUPPLEMENTS
(E.G., VITAMINS, MINERALS)
28. 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 11 - OWNER, OPERATOR, OR AGENT-IN-CHARGE INFORMATION

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 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 12 - INSPECTION STATEMENT
 
 
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 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