FDA-3613d.p65 wwragg

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Specifications	FDA-3613d.p65 wwragg
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GENERALQuantity: (Note: no specific products will be listed.) PRODUCT SPECIFICQuantity: You must type a “PRODUCT LIST&#

Specifications	FDA-3613d.p65 wwragg
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Content	GENERALQuantity: (Note: no specific products will be listed.) PRODUCT SPECIFICQuantity: You must type a “PRODUCT LIST” for each certificate requested. This Product List will be attached to your export Certificate. For each product include the exact brand name as it appears on the label. (Note: do NOT submit product labels or literature.) Special instructions: OFFICE OF COSMETICS AND COLORS “CERTIFICATE” (EXPORTS) APPLICATION EF PSC Graphics (301) 443-1090 Form Approved: OMB No. 0910-0498;Expiration Date: 3/31/09 Department of Health and Human Services Food and Drug Administration Center for Food Safety and Applied Nutrition Date 1.Requester Information Company name Contact person name Contact phone Address StateZIP/postal codeContact fax Contact emailCountry 2.Exporting Company Information (the name and address to appear on the certificate) 3.Type of “Certificate” Requested 4.Send Certificate To Company name Contact person name, phone, email Address FORM FDA 3613d (2/06)Page 1 of 2 5.Certificate Delivery Your account numberCarrier name (express mail) 6.Fees 7.Signature Name and TitleSignature 1 above2 above “The requester hereby presents and acknowledges that the company is aware that in making this request the company is subject to the terms and provisions of Title 18, Section 1001, United States Code which makes it a criminal offense to falsify, conceal, or cover up a material fact; make any material false, fictitious, or fraudulent statement or representation; or make or use any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry.” Date City $10 for each certificate. Do not send money. You will receive an invoice. Certificates will be mailed via the U.S. Postal Service (regular mail) unless you make special arrangements as follows: Send Invoice To1 above2 above CityZIP codeState Company name Contact person name Contact phone Address StateZIP/postal codeContact fax Contact emailCountry City Other, describe: Save As.Print Next Page Reset Form
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Following Datasheets	UCM052399_1 (2 pages) UCM052402_1 (1 pages) UCM052460 (25 pages) UCM053308_1 (1 pages) UCM053338_1 (2 pages) UCM053435_1 (2 pages) UCM053438_1 (2 pages) UCM053453_1 (1 pages) UCM053459_1 (1 pages) UCM053474_1 (1 pages)
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