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Registration and US Agent Form

Registration and US Agent Form

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Submitter Information
Your Name*
Prefix First Last
Phone Number (Include Area/Country Code)*
Email*

Facility Address Information
Facility Name*
Facility Name Suffix
Other
Facility Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email Address*
Phone Number (Include Area/Country Code)*
Fax (Include Area/Country Code)
Is the preferred mailing address the same as the facility address?
- Yes
- No
Mailing Address Information
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email Address*
Phone Number (Include Area/Country Code)*
Fax (Include Area/Country Code)
Is the parent company address the same as the facility address or preferred mailing address?
- Same as Facility Address
- Same as Preferred Mailing Address
- None of the above
Parent Company Name/Address Information
Parent name*
Parent Company Address Information*
Street Address City State / Province / Region ZIP / Postal Code Country
Email Address*
Phone Number (Include Area/Country Code)*
Fax (Include Area/Country Code)
Emergency Contact Information
If information is the same as another section, check which section:
- Same as Facility Address
- Same as Submitter Information
- Other
Contact Name*
Prefix First Last
Contact Phone (Include Area/Country Code)*
Contact Email Address*
Trade Names
If this facility uses trade names other than previously mentioned, list them here (e.g., "Also doing business as," "Facility also known as")
Are there alternate trade names used by your facility in addition to the name provided in previous sections?
- No
- Yes
Alternate Trade Name #1*
Alternate Trade Name #2*

Product information
General Product Categories - Human/Animal/Both*
- Food for Human Consumption
- Food for Animal Consumption
Select all the food categories for human consumption that are handled at facility:
- 1. ALCOHOLIC BEVERAGES
- 2. BABY (INFANT AND JUNIOR) FOOD PRODUCTS Including Infant Formula
- 3. BAKERY PRODUCTS, DOUGH MIXES, OR ICINGS
- 4. BEVERAGE BASES
- 5. CANDY WITHOUT CHOCOLATE, CANDY SPECIALTIES AND CHEWING GUM
- 6. CEREAL PREPARATIONS, BREAKFAST FOODS, QUICK COOKING / INSTANT CEREALS
- 7a. CHEESE AND CHEESE PRODUCT CATEGORIES, Soft, Ripened Cheese
- 7b. CHEESE AND CHEESE PRODUCT CATEGORIES, Semi-Soft Cheese
- 7c. CHEESE AND CHEESE PRODUCT CATEGORIES, Hard Cheese
- 7d. CHEESE AND CHEESE PRODUCT CATEGORIES, Other Cheeses and Cheese Products
- 8. CHOCOLATE AND COCOA PRODUCTS
- 9. COFFEE AND TEA
- 10. COLOR ADDITIVES FOR FOODS
- 11. DIETARY CONVENTIONAL FOODS OR MEAL REPLACEMENTS (Includes Medical Foods)
- 12a. DIETARY SUPPLEMENT CATEGORIES, Proteins, Amino Acids, Fats and Lipid Substances
- 12b. DIETARY SUPPLEMENT CATEGORIES, Vitamins and Minerals
- 12c. DIETARY SUPPLEMENT CATEGORIES, Animal By-Products and Extracts
- 12d. DIETARY SUPPLEMENT CATEGORIES, Herbals and Botanicals
- 13. DRESSING AND CONDIMENTS
- 14a. FISHERY / SEAFOOD PRODUCT CATEGORIES, Fin Fish, Whole or Filet
- 14b. FISHERY / SEAFOOD PRODUCT CATEGORIES, Molluscan Shellfish
- 14c. FISHERY / SEAFOOD PRODUCT CATEGORIES, Other Shellfish
- 14d. FISHERY / SEAFOOD PRODUCT CATEGORIES, Ready to Eat (RTE) Fishery Products
- 14e. FISHERY / SEAFOOD PRODUCT CATEGORIES, Processed and Other Fishery Products
- 15. FOOD ADDITIVES, GENERALLY RECOGNIZED AS SAFE (GRAS) INGREDIENTS, OR OTHER INGREDIENTS USED FOR PROCESSING
- 16. FOOD SWEETENERS (NUTRITIVE)
- 17a. FRUIT AND FRUIT PRODUCTS, Fresh Cut Produce
- 17b. FRUIT AND FRUIT PRODUCTS, Raw Agricultural Commodities
- 17c. FRUIT AND FRUIT PRODUCTS, Other Fruit and Fruit Products
- 18. FRUIT OR VEGETABLE JUICE, PULP OR CONCENTRATE PRODUCTS
- 19. GELATIN, RENNET, PUDDING MIXES, OR PIE FILLINGS
- 20. ICE CREAM AND RELATED PRODUCTS
- 21. IMITATION MILK PRODUCTS
- 22. MACARONI OR NOODLE PRODUCTS
- 23. MEAT, MEAT PRODUCTS AND POULTRY (FDA REGULATED)
- 24. MILK, BUTTER, OR DRIED MILK PRODUCTS
- 25. MULTIPLE FOOD DINNERS, GRAVIES, SAUCES AND SPECIALTIES
- 26a. NUTS AND EDIBLE SEED PRODUCT CATEGORIES, Nut and Nut Products
- 26b. NUTS AND EDIBLE SEED PRODUCT CATEGORIES, Edible Seed and Edible Seed Products
- 27. PREPARED SALAD PRODUCTS
- 28a. SHELL EGG AND EGG PRODUCT CATEGORIES, Chicken Egg and Egg Products
- 28b. SHELL EGG AND EGG PRODUCT CATEGORIES, Other Eggs and Egg Products
- 29. SNACK FOOD ITEMS (FLOUR, MEAL OR VEGETABLE BASE)
- 30. SPICES, FLAVORS, AND SALTS
- 31. SOUPS
- 32. SOFT DRINKS AND WATERS
- 33a. VEGETABLE AND VEGETABLE PRODUCT CATEGORIES, Fresh Cut Products
- 33b. VEGETABLE AND VEGETABLE PRODUCT CATEGORIES, Raw Agricultural Commodities
- 33c. VEGETABLE AND VEGETABLE PRODUCT CATEGORIES, Other Vegetable and Vegetable Products
- 34. VEGETABLE OILS (INCLUDES OLIVE OIL)
- 35. VEGETABLE PROTEIN PRODUCTS (SIMULATED MEATS)
- 36. WHOLE GRAINS, MILLER GRAIN PRODUCTS (FLOURS), OR STARCH
- 37. OTHER
IF NONE OF THE ABOVE FOOD CATEGORIES APPLY, THEN PRINT THE APPLICABLE FOOD CATEGORY OR CATEGORIES (THAT DOES NOT OR DO NOT APPEAR ABOVE).
Select all the food categories for animal consumption that are handled at facility:
- 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. OTHER
IF NONE OF THE ABOVE FOOD CATEGORIES APPLY, THEN PRINT THE APPLICABLE FOOD CATEGORY OR CATEGORIES (THAT DOES NOT OR DO NOT APPEAR ABOVE).

Select all the activities conducted at the facility:*
- Manufacturer / Processor
- Ambient Food Storage Warehouse / Holding Facility
- Labeler / Relabeler
- Refrigerated Food Storage Warehouse / Holding Facility
- Packer / Repacker
- Frozen Food Storage Warehouse / Holding Facility
- Low-Acid Food Processor
- Acidified Food Processor
- Farm Mixed-Type Facility
- Other
If the type of activity you perform is not listed, please indicate the type of activity you perform on each food category here:

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. The owner or operator in charge of the facility also authorizes register-FDA to submit the registration on the facility's behalf and FDA will be permitted to inspect the facility at the time and in the manner permitted by the Federal Food, Drug, and Cosmetic Act. Our Terms & Conditions apply.
- I agree.*
Terms and Conditions*
- I have read and agree to the Terms and Condition
Terms and Conditions

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