Drug Establishment Registration Form 1. Establishment Name* Street Address* City State Country Postal Code FDA Registration Number DUNS Number 2. Establishment Contact Contact Person Name* Job Title* Mailing Address* City* State* Country* Postal Code* E-mail* Tel Number* 3. Type of Operation Manufacture Repack Relabel API Manufacture Private Label Distribution Brand Owner Analytical Lab Sterilize Other (explain) 4. Drug Status OTC Prescription API Veterinary Homeopathic 5. Additional Information Drug Name Active Ingrediant 1 Assay Value / % Active Ingrediant 2 Assay Value / % Submitter Name: Job Title: Submitter E-mail: Your message was sent successfully. We will contact you soon.
