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FDA Food Facility Registration

DOMESTIC REGISTRATION FOREIGN REGISTRATION
INITIAL REGISTRATION UPDATE OF REGISTRATION INFORMATION BIENNIAL REGISTRATION RENEWA
  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?
If "Yes", provide the following information, if known.
Yes No
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/CountryCode

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 – TYPE OF STORAGE
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 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 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
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Agreement for FDA Food Facility Registration and US Agent service

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using 'Content here, content here', making it look like readable English. Many desktop publishing packages and web page editors now use Lorem Ipsum as their default model text, and a search for 'lorem ipsum' will uncover many web sites still in their infancy. Various versions have evolved over the years, sometimes by accident, sometimes on purpose (injected humour and the like).

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using 'Content here, content here', making it look like readable English. Many desktop publishing packages and web page editors now use Lorem Ipsum as their default model text, and a search for 'lorem ipsum' will uncover many web sites still in their infancy. Various versions have evolved over the years, sometimes by accident, sometimes on purpose (injected humour and the like).

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using 'Content here, content here', making it look like readable English. Many desktop publishing packages and web page editors now use Lorem Ipsum as their default model text, and a search for 'lorem ipsum' will uncover many web sites still in their infancy. Various versions have evolved over the years, sometimes by accident, sometimes on purpose (injected humour and the like).

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using 'Content here, content here', making it look like readable English. Many desktop publishing packages and web page editors now use Lorem Ipsum as their default model text, and a search for 'lorem ipsum' will uncover many web sites still in their infancy. Various versions have evolved over the years, sometimes by accident, sometimes on purpose (injected humour and the like).
Submitter name Job Title Submitter E-mail
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