PCG | COSMETIC FACILITY REGISTRAION FORM

Cosmetic Facility Registration Form

* indicates required field

Type of submission

Initial

Amended

Biennial renewal

Abbreviated renewal

if amended, choose one box

Changes to registration

Cancellation of registration

Is this a facility registration for a small business (optional registration)?

Yes

Name of the owner and/or operator of the facility

Facility Name

Street Address

City

State

Country

Phone Number

Facility Email

Facility D&B D-U-N-S Number

Brand Names

Responsible Person Name

Product Category

Brand Names

Responsible Person Name

Product Category

Brand Names

Responsible Person Name

Product Category

Brand Names

Responsible Person Name

Product Category

Brand Names

Responsible Person Name

Product Category

If you have more brands, please send the information to ask@provisionfda.com

U.S. Agent Name

Phone

Thanks for submitting!