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

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)?

Yes

Name of Owner / Representative

Facility Name

Street Address

City

State

Country

Phone Number

Facility Email

FEI Number

Product Information

Responsible Person should be either the manufacturer, distributor, or packer's company name.

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!