Form FDA 3613e FDA 3613e Food Export Certificate Application

Export Certificates for FDA Regulated Products under U.S.C. Sections 801(e) and 802

3613e_updated

Costs of Certificates

OMB: 0910-0498

Document [pdf]
Download: pdf | pdf
   

Form Approval: OMB No.0910-0498

 

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

   

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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.

 

 

 

 
      * - These fields are required

 
 

*MANUFACTURER NAME
Test Foods, Inc.

 

DOING BUSINESS AS NAME
Test Foods, Inc.

 

*STATE LICENSE/REGISTRATION NUMBER
19422594594

 

*COUNTRY
United States

 

*ADDRESS LINE1
35456 Telegraph RD

 

ADDRESS LINE2

 

*ZIP/POSTAL CODE
20852

 

*CITY
Rockville

 

*STATE OR PROVINCE
Maryland

 

*CONTACT PERSON NAME
John Smith

 
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

     

1

301

7709610

 

CONTACT EMAIL
[email protected]

 

 

***This section is optional. If you intend to complete this section, the
fields marked with *** are necessary for the system to process a
complete response.

 
 

***EXPORT COMPANY NAME
Test Marine Enterprise

 

STATE LICENSE/REGISTRATION NUMBER
070085236

 

***COUNTRY
UNITED
UNITEDSTATES
STATES

 

***ADDRESS LINE1
1101 South Fort Harrison Avenue

 

ADDRESS LINE2

 

***ZIP/POSTAL CODE
33756

 

***CITY
Clearwater
Clearwater

 

***STATE OR PROVINCE
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

     

001

727

4434900

 

***CONTACT EMAIL
[email protected]

 

 
 

 

 

 

 

 
 
Select

Product

Common Name

Manufacturer

Description/Comments

Cichlid fish

Tilapia

Test Foods, Inc

10 Cases @ 100 lbs

Siluriformes

Catfish

Test Foods, Inc

5 Cases @ 100 lbs

Mackerel

Scombridae

Test Foods, Inc

10 Cases @ 100 lbs

 

 

 

 
 

 

 

 

 

 

 

 
 
*NAME OF COUNTRY or COUNTRIES
AFGHANISTAN
AFGHANISTAN
ALAND
ALAND ISLANDS
ISLANDS
ALBANIA
ALBANIA
ALGERIA
ALGERIA SAMOA
AMERICAN
AMERICAN SAMOA
ANDORRA

 

 
*SEND CERTIFICATE TO
MANUFACTURER

DISTRIBUTOR

 
 

*FIRM NAME

 

COUNTRY
Please
Country
PleaseSelect
Select
Country

 

*ADDRESS LINE1

 

ADDRESS LINE2

 

*ZIP/POSTAL CODE

 

*CITY
--Please
--PleaseSelect-Select--

 

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

*CONTACT PERSON NAME

OTHER (provide the below information)

 
 

 
 

 

 

 

 

 

 
 
 

*CARRIER NAME (U.S. Mail, FedEx, etc.)
US
USMail
Mail

 

ACCOUNT NUMBER (If applicable)

 

Fees are $10 per certificate, and will be billed upon receipt of this
application.

 
Copies of Certificate : 1

(Number of copies)

Total                       :

$

10

 

 
 

 

 

 

 

 

 
 
(Attach an electronic copy of any applicable product label(s). A fax copy is
accepted only if it is readable.)
(Maximum allowed file size is 10 MB.
If the file size is more than 10 MB, Please send the hardcopy file via mail.
Accepted File Types: jpg,doc,docx,txt,xls,xlsx,pdf,gif and rtf)
SELECT THE FILE TO UPLOAD:  
no file selected

 
The undersigned verifies that all ingredients are approved for use by FDA or
appear on the GRAS list, and each product is intended for human consumption
and is available for sale in the U.S. without restriction.
 
*NAME:
Dennis Hall

 
*TITLE:
Export Chief
✔

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: Seafood

MANUFACTURER NAME: Test Foods,Inc.
DOING BUSINESS AS NAME: Test Foods,Inc.
STATE LICENSE/REGISTRATION NUMBER: 19422594594
ADDRESS Line1: 35456 Telegraph RD
ADDRESS Line2: 
CITY: Rockville

STATE/TERRITORY: Maryland

ZIP CODE: 20852

COUNTRY: UNITED STATES

TELEPHONE NUMBER:  1 301  7709610 

FAX NUMBER:     

CONTACT PERSON NAME: John Smith

EMAIL ADDRESS: [email protected]

EXPORT COMPANY NAME: Test Marine Enterprise
STATE LICENSE/FDA REGISTRATION NUMBER: 070085236
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]

Product

Common Name

Manufacturer

Description/Comments
10 Cases @ 100 lbs

Cichlid fish

Tilapia

Test Foods, Inc

Siluriformes

Catfish

Test Foods, Inc

5 Cases @ 100 lbs

Mackerel

Scombridae

Test Foods, Inc

10 Cases @ 100 lbs

NAME OF COUNTRY or COUNTRIES: UNITED STATES

SEND CERTIFICATE TO 
✔
Manufacturer
Exporting Company

Other

CARRIER NAME (U.S. Mail, FedEx, etc.): US Mail
ACCOUNT NUMBER (If applicable): 

Copies of certificate:  5

Total fee for 5 certificate:  50

LABEL(S):

The undersigned verifies that all ingredients are approved for use by FDA or appear on the GRAS list, and each product is
intended for human consumption and is available for sale in the U.S. without restriction.
Name: Dennis Hall
Title: Export Chief
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.

 
 


File Typeapplication/pdf
File TitleCertificate Application Process Main Menu
File Modified2012-03-21
File Created2012-02-13

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