Download:
pdf |
pdf
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.
* - 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 Type | application/pdf |
| File Title | Certificate Application Process Main Menu |
| File Modified | 2012-03-21 |
| File Created | 2012-02-13 |