DHHWFDA
- CANCELLATION OF FOOD FACILITY REGISTRATION |
| PROVIDE THE FACILITY
REGISTRATION NUMBER: |
|
|
DOMESTIC REGISTRATION |
FOREIGN REGISTRATION |
FACILITY NAME
/ ADDRESS INFORMATION |
| FACILITY
NAME:
|
| FACILITY
STREET ADDRESS:
|
| CITY:
|
STATE:
|
| ZIP CODE (POSTAL
CODE):
|
PROVINCE/TERRITORY:
|
| COUNTRY:
|
CERTIFICATION
STATEMENT |
| The
owner, operator, or agent in charge of the facility
must submit this form. By submitting this form to
FDA, the owner, operator, or agent in charge certifies
that the above information is true and accurate and
that the facility has authorized the submitter to
cancel the registration on its behalf, under I8 U.S.
C. 1001, anyone who makes a materially false, fictitious,
or fraudulent statement to the U.S. Government is
subject to criminal penalties.
|
| PRINT
NAME OF PERSON SUBMIlTING THE CANCELLATION FORM
|
| ADDRESS
|
E-MAIL ADDRESS
(IF AVAILABLE)
|
FDA USE
ONLY |
| DATE CANCELLATION
FORM RECEIVED |
DATE CONFIRMATION
SENT TO FACILITY |
|
|
Public
reporting burden for this collection of information is estimated
to average 1 hour per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions
for reducing this burden to: |
Department
of Health and Human Services
Food and Drug Administration
CFSAN (HFS-024)
5100 Paint Branch Parkway
College Park, MD 20740 |
An
agency may not conduct or sponsor, and a parson is not requied to
respond to a collection of information unless it displays a currently
valid OMB control number. |
