Form FDA 3613d FDA 3613d Office of Cosmetics and Colors "Certificate" (Exports) A

Form Approval: OMB No.0910-0498

Expiration date: TBA*
See OMB Statement at end of form

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
OMB control number.

Please Note:

The system will automatically time out if there is no activity for 30
minutes and you will need to re-do your work from the beginning.

*COMPANY NAME
Test Requester

COUNTRY
UNITED
UNITEDSTATES
STATES

*ADDRESS LINE1
2003 P Street Northwest

ADDRESS LINE2

*ZIP/POSTAL CODE
20036

*CITY
Washington
Washington

*STATE
District
DistrictofofColumbia
Columbia

*CONTACT PERSON NAME
Ryan Brown

Numbers only. No spaces, dashes or parentheses. Country Code not
required for US phone numbers.

          Country
Code

Area/City
Code

Phone Number

Extension

          (e.g.033)

(e.g.101)

(e.g.5551111)

(e.g.1111)

*CONTACT
PHONE

001
Country

202
Area/City

6383434

Fax Number

          Code

Code

          (e.g.033)

(e.g.101)

CONTACT FAX

(e.g.5551111)

*CONTACT EMAIL
[email protected]

*COMPANY NAME
Test Marine Enterprise

*COUNTRY
UNITED
UNITEDSTATES
STATES

*ADDRESS LINE1
1101 South Fort Harrison Avenue

ADDRESS LINE2

*ZIP/POSTAL CODE
33756

*CITY
Clearwater
Clearwater

*STATE
Florida
Florida

*CONTACT PERSON NAME
Dennis Hall

Numbers only. No spaces, dashes or parentheses. Country Code not
required for US phone numbers.

          Country
Code

Area/City
Code

Phone Number

Extension

          (e.g.033)

(e.g.101)

(e.g.5551111)

(e.g.1111)

*CONTACT
PHONE

          Country
Code

Area/City
Code

Fax Number

          (e.g.033)

(e.g.101)

(e.g.5551111)

CONTACT FAX

*CONTACT EMAIL

001

727

4434900

[email protected]

GENERAL Quantity:

3

(Note: no specific products will be listed).

- OR PRODUCT SPECIFIC Quantity:

You must type a "PRODUCT LIST" for each certificate

requested. This Product List will be attached to your export Certificate. For each product include the
exact name as it appears on the label. (Note: do NOT submit product labels or literature.)

Special Instructions:

*SEND CERTIFICATE TO
SECTION 1 - REQUESTER
SECTION 2 - DISTRIBUTOR
OTHER (provide the below information)

*COMPANY NAME

COUNTRY
Please
Country
PleaseSelect
Select
Country

*ADDRESS LINE1

ADDRESS LINE2

*ZIP CODE

*CITY

--PleaseSelect-Select---Please

*STATE
--Please
--PleaseSelect-Select--

* CONTACT PERSON NAME

Numbers only. No spaces, dashes or parentheses. Country Code not
required for US phone numbers.

          Country
Code

Area/City
Code

Phone Number

Extension

          (e.g.033)

(e.g.101)

(e.g.5551111)

(e.g.1111)

*CONTACT
PHONE

*CONTACT EMAIL

*SEND INVOICE TO
SECTION 1 - REQUESTER
SECTION 2 - DISTRIBUTOR

Certificates will be mailed via the U.S. Postal Service (Regular Mail) unless you
make special arrangements as follows.

*CARRIER NAME (express mail)
US
USMail
Mail

YOUR ACCOUNT NUMBER

$10 for each certificate. Do not send money. You will receive an invoice.

The requester hereby presents and acknowledges that the company is aware that
in making this request the company is subject to the terms and provisions of Title
18, Section 1001, United States Code which makes it a criminal offense to falsify,
conceal, or cover up a material fact; make any material false, fictious, or
fradulent statement or representation; or make or use any false writing or
document knowing the same to contain any materially false, fictious, or
fraudulent statement or entry.

*NAME:
Ryan Brown

*TITLE:
Export Officer
✔

I Agree.

Please review your application. If all information is correct, click the Submit button below. To make changes to a
section, click the Edit button for that section.
Date:02/08/2012 16:48:40
Created Date:

Application Status:

Certificate Type: Color

COMPANY NAME: Test Requester
ADDRESS Line1: 2003 P Street Northwest
ADDRESS Line2: 
CITY: Washington

STATE/TERRITORY: District of Columbia

ZIP CODE: 20036

COUNTRY: UNITED STATES

TELEPHONE NUMBER:  1 202 6383434  

FAX NUMBER:     

CONTACT PERSON NAME: Ryan Brown

EMAIL ADDRESS: [email protected]

COMPANY NAME: Test Marine Enterprise
ADDRESS Line1: 1101 South Fort Harrison Avenue
ADDRESS Line2: 
CITY: Clearwater

STATE/TERRITORY: Florida

ZIP CODE: 33756

COUNTRY: United States

TELEPHONE NUMBER: 001  727 4434900;  

FAX NUMBER:     

CONTACT PERSON NAME: Dennis Hall

EMAIL ADDRESS: [email protected]

GENERAL Quantity:

5

(Note: no specific products will be listed).

SEND CERTIFICATE TO: 
✔ Requester
Exporting Company

Other

SEND INVOICE TO: 
✔ Requester
Exporting Company

Certificates will be mailed via the U.S. Postal Services (Regualr Mail), unless you make special arrangements as follows.

CARRIER NAME (express mail): US Mail
YOUR ACCOUNT NUMBER: 

$10 for each certificate. Do not send Money. You will receive an invoice.

The requester hereby presents and acknowledges that the company is aware that in making this request the company is
subject to the terms and provisions of Title 18, Section 1001, United States Code which makes it a criminal offense to falsify,
conceal, or cover up a material fact; make any material false, fictious, or fradulent statement or representation; or make or use
any false writing or document knowing the same to contain any materially false, fictious, or fraudulent statement or entry.
Name: Ryan Brown
Title: Export Officer
Date: 02/08/2012 16:48:40
✔

I Agree.
Not For Public Disclosure

Your Application Number is 1513.
Please keep the Application number for your records. The Application number is required for all
communications with FDA regarding this application. Please refer to the help section for more
details.