A.A. SAYIA & COMPANY, INC.
FDA Registration Form

Complete the form below. When finished, click SUBMIT once. Note that mandatory fileds are indicated with an asterisk (*)

Section 1 - TYPE OF REGISTRATION

* Please choose the type of registration:

DOMESTIC REGISTRATION

FOREIGN REGISTRATION

Section 2 - FACILITY NAME / ADDRESS INFORMATION

* Facility Name:

* Facility Street Address:

* City:

* State:

* Zip Code (Postal Code):

Province/Territory:

* Country:

* Phone Number (If a foreign facility, include Area & Country Codes):

FAX Number (If available; if foreign facility, include Area & Country Codes):

E-mail Address (if available):

Section 3 - OPTIONAL: PREFERRED MAILING ADDRESS INFORMATION (only complete this section if different from section 2, facility Name/Address Information)

Name:

Address:

City:

State:

Zip Code (Postal Code):

Province/Territory:

Country:

Phone Number (If a foreign facility, include Area & Country Codes):

FAX Number (If available; if foreign facility, include Area & Country Codes):

Section 4 - PARENT COMPANY NAME / ADDRESS INFORMATION (IF APPLICABLE)

Name of Parent Company:

Street Address of Parent Company:

City:

State:

Zip Code (Postal Code):

Province/Territory:

Country:

Phone Number (If a foreign facility, include Area & Country Codes):

FAX Number (If available; if foreign facility, include Area & Country Codes):

Section 5 - FACILITY EMERGENCY CONTACT INFORMATION

* Individual's Name:

* Title:

* Office Phone (If a foreign facility, include Area & Country Codes):

* Home Phone (If a foreign facility, include Area & Country Codes):

Cell Phone (If available; if a foreign facility, include Area & Country Codes):

Section 6 - TRADE NAMES (If this facility uses trade names other than that listed in section 2 above, list them below (E.G., "also doing business as," "facility also known as"):

Alternate Trade name #1:

Alternate Trade name #2:

Section 7 - GENERAL PRODUCT CATEGORIES - FOOD FOR HUMAN CONSUMPTION

Please check one or more of the following categories that are appliable to you. Click on the question mark (?) for more information

NUT AND EDIBLE SEED PRODUCTS [21 CFR 170.3 (n) (26), (32)]

SPICES, FLAVORS AND SALTS [21 CFR 170.3 (n) (26)]

VEGETABLES AND VEGETABLE PRODUCTS [21 CFR 170.3 (n) (19), (36)]

Section 8 - CERTIFICATION STATEMENT

The owner, operator, or agent in charge of the facility must submit this form. By submitting this form, the owner, operator or agent in charge certifies that the information is true and accurate and that the facility has authorized the submitter to register on it's behalf. Under 18 U.S.C 1001, anyone who makes a materially false, fictious or fraudulent statement to the U.S. Govermnment is subject to criminal penalties.

* Type in the FULL NAME of the person submitting this form:

* Phone Number (If a foreign facility, include Area & Country Codes):

FAX Number (If available; if foreign facility, include Area & Country Codes):

* Indicates Response Required

A.A. SAYIA & COMPANY, INC. FDA Registration Form

Section 1 - TYPE OF REGISTRATION

Section 2 - FACILITY NAME / ADDRESS INFORMATION

Section 3 - OPTIONAL: PREFERRED MAILING ADDRESS INFORMATION (only complete this section if different from section 2, facility Name/Address Information)

Section 4 - PARENT COMPANY NAME / ADDRESS INFORMATION (IF APPLICABLE)

Section 5 - FACILITY EMERGENCY CONTACT INFORMATION

Section 6 - TRADE NAMES (If this facility uses trade names other than that listed in section 2 above, list them below (E.G., "also doing business as," "facility also known as"):

Section 7 - GENERAL PRODUCT CATEGORIES - FOOD FOR HUMAN CONSUMPTION

Section 8 - CERTIFICATION STATEMENT

A.A. SAYIA & COMPANY, INC.
FDA Registration Form