3757 DHHS/FDA Menu and Vending Machine Labeling Voluntary Reg

Form Approved: OMB Nos. 0910-0782 & 0910-0783;

Expiration Date: 03/31/2018; See PRA Statement on the last page.
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 Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

State

Name of Official on Site

On-site Official's Phone Number

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

On-site Official's E-mail
(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

Form FDA 3757 (7/10)

State

Zip Code

City

Page 1 of 7

Zip Code

E-mail of Official on Site

State

Zip Code

DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

Business Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

State

Name of Official on Site

On-site Official's Phone Number

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

On-site Official's E-mail
(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

State

Zip Code

City

Business Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

Form FDA 3757 (7/10)

State

Zip Code

City

Page 2 of 7

E-mail of Official on Site

State

Zip Code

State

Zip Code

Name of Official on Site

On-site Official's Phone Number

On-site Official's E-mail

Zip Code

E-mail of Official on Site

State

Zip Code

DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

Business Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

State

Name of Official on Site

On-site Official's Phone Number

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

On-site Official's E-mail
(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

State

Zip Code

City

Business Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

Form FDA 3757 (7/10)

State

Zip Code

City

Page 3 of 7

E-mail of Official on Site

State

Zip Code

State

Zip Code

Name of Official on Site

On-site Official's Phone Number

On-site Official's E-mail

Zip Code

E-mail of Official on Site

State

Zip Code

DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

Business Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

State

Name of Official on Site

On-site Official's Phone Number

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

On-site Official's E-mail
(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

State

Zip Code

City

Business Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

Form FDA 3757 (7/10)

State

Zip Code

City

Page 4 of 7

E-mail of Official on Site

State

Zip Code

State

Zip Code

Name of Official on Site

On-site Official's Phone Number

On-site Official's E-mail

Zip Code

E-mail of Official on Site

State

Zip Code

DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

Business Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

State

Name of Official on Site

On-site Official's Phone Number

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

On-site Official's E-mail
(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

State

Zip Code

City

Business Name

Business Name

All Trade Names

All Trade Names

(if applicable)

(if applicable)

Business Address

Business Address

City

State

Zip Code

City

Business Phone

Business Phone

Business E-mail

Business E-mail

Official

Name of Official on Site

Official

On-site Official's Phone Number

(if different than business phone)

(if different than business phone)

(if different than business)

E-mail of Official on Site

On-site Official's E-mail
(if different than business)

Mailing Address

Mailing Address

(if different than business address)

(if different than business address)

City

Form FDA 3757 (7/10)

State

Zip Code

City

Page 5 of 7

E-mail of Official on Site

State

Zip Code

State

Zip Code

Name of Official on Site

On-site Official's Phone Number

On-site Official's E-mail

Zip Code

E-mail of Official on Site

State

Zip Code

DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION

Business Name
All Trade Names
(if applicable)

Business Address
City

State

Zip Code

Business Phone
Business E-mail
Official

Name of Official on Site

On-site Official's Phone Number
(if different than business phone)

On-site Official's E-mail
(if different than business)

E-mail of Official on Site

Mailing Address
(if different than business address)

City

Form FDA 3757 (7/10)

State

Zip Code

Page 6 of 7

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, CFSAN Menu and Vending Machine Registration, White Oak
Building 22, Rm. 0209, 1903 New Hampshire Ave., Silver Spring, MD 20993.
Or you can Fax a completed form to (301) 436-2804.
The time required to complete this collection of information is estimated to average 2 hours per response,
including the time to review instructions, search existing data sources, gather and maintain the data
needed, and complete and review 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:
FDA PRA Staff
Office of Operations
Food and Drug Administration
8455 Colesville Rd., COLE-14526
Silver Spring, MD 20993-0002
or email to [email protected]

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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