FDA Bioterrorism - Registration Form

* = Required Fields

Foreign Facility

* Served by UTi Branch/City

Domestic Facility

Section 1: Facility Information (Note: If a required field does not apply, enter "None".)
* Facility Name
* Facility Street Address, Line 1
Facility Street Address, Line 2
* City	* State
* Zip Code (Postal Code)	* Province / Territory
* Country	* Phone No (Include Country/Area or City code)
* Fax No (Include Country/Area or City code)	* eMail Address

Section 2: Preferred Mailing Address Information (Note: Complete this section ONLY if different from Section 1 above.)
Name
Street Address, Line 1
Street Address, Line 2
City	State
Zip Code (Postal Code)	Province / Territory
Country	Phone No (Include Country/Area or City code)
Fax No (Include Country/Area or City code)	eMail Address

Section 3: Parent Company Information
* Name of Parent Company
Street Address of Parent Company, Line 1
Street Address of Parent Company, Line 2
City	State
Zip Code (Postal Code)	Province / Territory
Country	Phone No (Include Country/Area or City code)
Fax No (Include Country/Area or City code)	eMail Address

Section 4: Facility Business Description and Contact Information (Note: If a required field does not apply, enter "None". For Fax, Mobile & Home Phone numbers, enter the Primary Contact details.)
* Facility Business Description
* Type of Establishment
* Facility Trade Name
* Name of Primary Contact	* Title of Primary Contact
* Fax No (Include Country/Area or City Code)	* eMail Address of Primary Contact
* Mobile Phone (Include Country/Area or City Code)	* Home Phone (Include Country/Area or City code)

* Section 5: Description of Articles Manufactured, Stored, Processed, Labeled or Packed

* Section 6: General Product Categories - Food for Human Consumption
To be completed by all food facilities. If NONE of the mandatory categories apply, select box 37.

1.	Alcoholic Beverages [21 CFR 170.3 (n) (2)]	2.	Baby (Infant And Junior) Food Products Including Infant Formula (Optional Selection)
3.	Bakery Products, Dough Mixes Or Icings [21 CFR 170.3 (n) (1), (9)]	4.	Beverage Bases [21 CFR 170.3 (n) (3), (16), (35)]
5.	Candy Without Chocalate, Candy Specialties & Chewing Gum [21 CFR 170.3 (n) (6), (9), (25), (38)]	6.	Cereal Preparations, Breakfast Foods, Quick Cooking/instant Cereals [21 CFR 170.3 (n) (4)]
7.	Cheese And Cheese Products [21 CFR 170.3 (n) (5)]	8.	Chocolate And Cocoa Products [21 CFR 170.3 (n) (3), (9), (38), (43)]
9.	Coffee And Tea [21 CFR 170.3 (n) (3), (7)]	10.	Color Additives For Foods [21 CFR 170.3 (o) (4)]
11.	Dietary Conventional Foods Or Meal Replacements	12.	Dietary Supplements:
	(includes Medical Foods) [21 CFR 170.3 (n) (31)]		Proteins, Amino Acids, Fats and Lipid Substances [21 CFR 170.3 (o) (20)]
			Vitamins and Minerals [21 CFR 170.3 (o) (20)]
			Animal By-Products and Extracts (Optional Selection)
			Herbals and Botanicals (Optional Selection)
13.	Dressings And Condiments [21 CFR 170.3 (n) (8), (12)]	14.	Fishery/seafood Products [21 CFR 170.3 (n) (13), (15), (39), (40)]
15.	Food Additives, Generally Recognized As Safe (gras) Ingredients, Or Other Ingredients Used For Processing [21 CFR 170.3 (n) (42); 21 CFR 170.3 (o) (1), (2), (3), (5), (6), (7), (8), (9), (10), (11), (12), (13), (14), (15), (16), (17), (18), (19), (22), (23), (24), (25), (26), (27), (28), (29), (30), (31), (32)]	16.	Food Sweeteners (nutritive) [21 CFR 170.3 (n) (9), (41); 21 CFR 170.3 (o) (21)]
17.	Fruits And Fruit Products [21 CFR 170.3 (n) (16), (27), (28), (35), (43)]	18.	Gelatin, Rennet, Pudding Mixes Or Pie Fillings [21 CFR 170.3 (n) (22)]
19.	Ice Cream And Related Products [21 CFR 170.3 (n) (20), (21)]	20.	Imitation Milk Products [21 CFR 170.3 (n) (10)]
21.	Macaroni Or Noodle Products [21 CFR 170.3 (n) (23)]	22.	Meat, Meat Products And Poultry (FDA Regulated) [21 CFR 170.3 (n) (17), (18), (29), (34), (39), (40)]
23.	Milk, Butter, Or Dried Milk Products [21 CFR 170.3 (n) (12), (30), (31)]	24.	Multiple Food Dinners, Gravies, Sauces And Specialties [21 CFR 170.3 (n) (11), (14), (17), (18), (23), (24), (29), (34), (40)]
25.	Nut And Edible Seed Products [21 CFR 170.3 (n) (26), (32)]	26.	Prepared Salad Products [21 CFR 170.3 (n) (11), (17), (18), (22), (29), (34), (35)]
27.	Shell Egg And Egg Products [21 CFR 170.3 (n) (11), (14)]	28.	Snack Food Items (flour, Meal Or Vegetable Base) [21 CFR 170.3 (n) (37)]
29.	Spices, Flavors And Salts [21 CFR 170.3 (n) (26)]	30.	Soups [21 CFR 170.3 (n) (39), (40)]
31.	Soft Drinks And Waters [21 CFR 170.3 (n) (3), (35)]	32.	Vegetables And Vegetable Products [21 CFR 170.3 (n) (19), (36)]
33.	Vegetable Oils (includes Olive Oil) [21 CFR 170.3 (n) (12)]	34.	Vegetable Protein Products (simulated Meats) [21 CFR 170.3 (n) (33)]
35.	Whole Grains, Miller Grain Products (flours), or Starch [21 CFR 170.3 (n) (1), (23)]	36.	Most/All Human Food Product Categories (Optional Selection)
37.	None Of The Above Mandatory Categories

Section 7: General Product Categories - Food For Animal Consumption (optional)

1.	Grain Products (e.g. Barley, Grain Sorghums, Maize, Oat, Rice, Rye And Wheat)	2.	Oilseed Products (e.g. Cottonseed, Soybeans, Other Oil Seeds)
3.	Alfalfa And Lespedeza Product	4.	Amino Acid
5.	Animal-derived Products	6.	Brewer Products
7.	Chemical Preservatives	8.	Citrus Products
9.	Distillery Products	10.	Enzymes
11.	Fats And Oils	12.	Fermentation Products
13.	Marine Products	14.	Milk Products
15.	Minerals	16.	Miscellaneous And Special Purpose Products
17.	Molasses	18.	Non-protein Nitrogen Products
19.	Peanut Products	20.	Recycled Animal Waste Products
21.	Screenings	22.	Vitamins
23.	Yeast Products	24.	Mixed Feed (Poultry, Livestock And, Equine)
25.	Pet Food	26.	Most/All Animal Food Product Categories

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