Register FDA | Assign US Agent Form

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Facility Information
Legal Company Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Contact Person Name*
First Last
Email*
Phone Number (Include Area/Country Code):*
Mobile Number (Include Area/Country Code):
Emergency Contact Information
- Check if it is same as Contact
Contact Name
First Last
Phone (Include Area/Country Code)
Contact Email Address

Certification Statement*
By submitting this form to register-FDA, or by authorizing an individual to submit this form to register-FDA, the owner or operator 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.
- I agree.*
Terms and Conditions*
- I have read and agree to the Terms and Conditions.
Terms and Conditions

Instructions for adding Register-FDA as your U.S. Agent will display after you submit this form. Thank you for your business.

US Agent for Food Facility Form