PCG | COSMETIC FACILITY REGISTRATION FORM

Cosmetic Facility Registration Form

This form is for clients that need to register a cosmetic facility with the FDA. If you need other facility registration or any other services, please send us an email first at ask@provisionfda.com and we will be in touch with you!

*Indicates required field

Type of Submission Required

Initial

Amended

Biennial Renewal

Abbreviated Renewal

For changes to current registration, please check the appropiate box below:

Changes to registration

Cancellation of registration

Facility Information

Please fill out the form with the facility that needs to be registered with the FDA. Kindly fill out a separate registration form for additional facilities needing to be registered.

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

Yes

Name of Owner / Representative

Facility Name

Street Address

City

State

Country

Phone Number

Facility Email

FEI Number

Product Information

Please Note:

The Brand Name should not include any symbols (e.g., ©, ®, ™, or special characters), as FDA does not permit the use of symbols.
The Responsible Person must be the name of the manufacturer, packer, or distributor as it appears on the product label.

1

Brand Name

Responsible Person Name

Product Category

2

Brand Name

Responsible Person Name

Product Category

3

Brand Name

Responsible Person Name

Product Category

4

Brand Name

Responsible Person Name

Product Category

5

Brand Name

Responsible Person Name

Product Category

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

U.S. Agent Contact Information

If we will be your US Agent, please go ahead and leave below fields blank.

US Agent Name

Phone

Thanks for submitting!