Form 3757 DHHS / FDA MENU AND VENDING MACHINE LABELING VOLUNTARY R

Form Approval: OMB No. 0910-0664;

Expiration Date: 01/31/2011; See Reporting Burden Statement on Page 4.
DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

TYPE OF REGISTRATION:

Initial Registration

Renewal

NAME OF AUTHORIZED OFFICIAL:
STREET ADDRESS OF AUTHORIZED OFFICIAL:
ADDRESS LINE 2 (OPTIONAL):
CITY:

ZIP CODE

STATE:

-

PHONE NUMBER OF AUTHORIZED OFFICIAL:
E-MAIL ADDRESS OF AUTHORIZED OFFICIAL:

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Form FDA 3757 (7/10)

Page 1 of 4

Zip Code

Zip Code

Form Approval: OMB No. 0910-0664;

Expiration Date: 01/31/2011; See Reporting Burden Statement on Page 4.
DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Form FDA 3757 (7/10)

Page 2 of 4

Zip Code

Zip Code

Zip Code

Zip Code

Form Approval: OMB No. 0910-0664;

Expiration Date: 01/31/2011; See Reporting Burden Statement on Page 4.
DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Business

Business

Address

Address

City

State

Zip Code

City

State

Official

Name of Official on Site

Official

Name of Official on Site

E-mail

E-mail of Official on Site

E-mail

E-mail of Official on Site

Business
Address
City

State

Official

Name of Official on Site

E-mail

E-mail of Official on Site

Form FDA 3757 (7/10)

Zip Code

Page 3 of 4

Zip Code

Zip Code

Zip Code

Form Approval: OMB No. 0910-0664;

Expiration Date: 01/31/2011; See Reporting Burden Statement on Page 4.
DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

CERTIFICATION STATEMENT:
This form may be submitted only by an authorized official of a restaurant or similar retail food
establishment that is not part of a chain with 20 or more locations, doing business under the
same name, regardless of the type of ownership of the locations, and offering for sale
substantially the same menu items, or an authorized official of a vending machine operator
that is not operated by a person who is engaged in the business of owning or operating 20 or
more vending machines. The authorized official certifies that each registered restaurant or
similar retail food establishment or each vending machine operator named herein elects to be
subject to the provisions of section 4205 of the Patient Protection and Affordable Care Act and
any implementing regulations. By submitting this form to FDA, the authorized official certifies
that the above information is complete, true and accurate. Under 18 U.S.C. 1001, anyone who
makes a materially false, fictitious, or fraudulent statement to the U.S. Government is subject
to criminal penalties.
SIGNATURE:
PRINT NAME:

DATE

MM/DD/YYYY

Check the box on the left if you are submitting this form electronically, to signify that your
printed name will serve as your signature.

INSTRUCTIONS
You can download the form, fill it out, save it on your computer and e-mail it to:
[email protected]
You can mail a completed copy to: FDA, HFS-681, 5600 Fishers Lane, Rockville, MD 20857.
Or you can Fax a completed form to (301) 436-2804.
Public reporting burden for this collection of information is estimated to average 2 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or another aspect of this collection of information, including suggestions for reducing this
burden to:

Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
1350 Piccard Drive, Room 400
Rockville, MD 20850

Please do NOT send this
form to this address

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid Office of Management and Budget (OMB) control number.
Form FDA 3757 (7/10)

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