PLEASE TYPE OR CLEARLY PRINT IN BLANK SPACES
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1. | Name of Firm | _______________________________________________________________________ | |||||||||||||||
2. | Street Address of Firm | _______________________________________________________________________ | |||||||||||||||
City | ___________________________________ State____________ Zip/Postal code__________
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Country | _________________________________________ | ||||||||||||||||
Telephone | _________________________________ Fax ___________________________________ | ||||||||||||||||
E-mail | _______________________________________________________________________ | ||||||||||||||||
3. |
Type of Firm (Check all that apply) | ||||||||||||||||
Manufacturer __________________ Packer/Repacker __________________
Retailer __________________ | |||||||||||||||||
Distributor __________________ Importer __________________ | |||||||||||||||||
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5. |
Average number of full-time equivalent employees for 12 month period
___________________
Include the owner of the firm as one employee. Do not list "0" employees. |
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6. | Report of units sold (Use continuation sheet if necessary) If new business, estimate number of units to be sold in upcoming year. | ||||||||||||||||
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7. | Name and address of Manufacturer(s), Distributor(s), or Importer(s) of Product(s) in Item 6 if Different from Firm Claiming an Exemption. (Use continuation sheet if necessary.) | ||||||||||||||||
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8. | Contact Person _______________________________________________________ Telephone Number ____________________ | ||||||||||||||||
9. | The undersigned certifies that the above information is complete and accurate. The undersigned will notify the Office of Nutritional Products, Labeling and Dietary Supplements of the date on which the average number of full-time equivalent employees or the number of units of products sold in the United States by my firm exceeds the applicable numbers for the time period for which the exemption is being claimed. | ||||||||||||||||
Signature ____________________________________________________________________________
Name (Type or clearly print) ______________________________________________________________ Title ________________________________________________________________________________ Date ________________________________________________________________________________ |