1. What types of products does your company handle?DrugsCosmeticsMedical DevicesOther FDA-Regulated ProductsFood, Beverages, or Dietary Supplements2. Contact information*Legal Company NameContact NameMobile NumberPhone 3. Does your facility currently have a valid U.S. FDA Registration Number?YesNo4. Provide facility information for Your Company.LimitedLimited by Guarantee (LTD)Public Limited Company (PLC)Unlimited (ULTD)Facility/Street Address* Street Address City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country • Is your facility Address same as your mailing address?YesNo5. Is this facility a subsidiary of a parent company? A parent company is a company that owns more than 50% of the shares of a subsidiaryYesNo6. Enter any trade names this facility operates under7. Provide information for the facility's emergency contact.Contact NameJob TitleE-mailPhone 8. This facility handles food forAdditives or Other Ingredients Used for ProcessingBeverage BasesCerealCheese or Cheese ProductsDietary SupplementsFishery or sea food productsChocolate and Cocoa ProductsFruit or Fruit ProductsNuts or edible Seed ProductsSnack food productsEgg ProductsRaw Agricultural CommoditiesWhole Grains, Milled Grain Products (Flours), StarchVegetable and Vegetable ProductsFood Consumption please choose from the following;9• Animal ConsumptionBotanicals and HerbsAnimal Protein ProductsChemical PreservativesFats and Oil Fermentation ProductsMilk ProductsMixed Feed (e.g. Poultry, Livestock, Equine)Vitamins and Vitamins ProductsYeast ProductsHuman Food By-Products Not Otherwise ListedGrain or Grain ProductsProcessed Animal Waste ProductsCompany Email* NOTE: PLEASE CLEARLY LIST YOUR PRODUCTS IF THEY ARE NOT ON THIS LIST ABOVE.
