Download:
pdf |
pdfForm Approval: OMB No. 0910-0664;
Expiration Date: 01/31/2011; See Reporting Burden Statement on Page 4.
DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION
TYPE OF REGISTRATION:
Initial Registration
Renewal
NAME OF AUTHORIZED OFFICIAL:
STREET ADDRESS OF AUTHORIZED OFFICIAL:
ADDRESS LINE 2 (OPTIONAL):
CITY:
ZIP CODE
STATE:
-
PHONE NUMBER OF AUTHORIZED OFFICIAL:
E-MAIL ADDRESS OF AUTHORIZED OFFICIAL:
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Form FDA 3757 (7/10)
Page 1 of 4
Zip Code
Zip Code
Form Approval: OMB No. 0910-0664;
Expiration Date: 01/31/2011; See Reporting Burden Statement on Page 4.
DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Form FDA 3757 (7/10)
Page 2 of 4
Zip Code
Zip Code
Zip Code
Zip Code
Form Approval: OMB No. 0910-0664;
Expiration Date: 01/31/2011; See Reporting Burden Statement on Page 4.
DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Business
Business
Address
Address
City
State
Zip Code
City
State
Official
Name of Official on Site
Official
Name of Official on Site
E-mail
E-mail of Official on Site
E-mail
E-mail of Official on Site
Business
Address
City
State
Official
Name of Official on Site
E-mail
E-mail of Official on Site
Form FDA 3757 (7/10)
Zip Code
Page 3 of 4
Zip Code
Zip Code
Zip Code
Form Approval: OMB No. 0910-0664;
Expiration Date: 01/31/2011; See Reporting Burden Statement on Page 4.
DHHS/FDA MENU AND VENDING MACHINE LABELING VOLUNTARY REGISTRATION
CERTIFICATION STATEMENT:
This form may be submitted only by an authorized official of a restaurant or similar retail food
establishment that is not part of a chain with 20 or more locations, doing business under the
same name, regardless of the type of ownership of the locations, and offering for sale
substantially the same menu items, or an authorized official of a vending machine operator
that is not operated by a person who is engaged in the business of owning or operating 20 or
more vending machines. The authorized official certifies that each registered restaurant or
similar retail food establishment or each vending machine operator named herein elects to be
subject to the provisions of section 4205 of the Patient Protection and Affordable Care Act and
any implementing regulations. By submitting this form to FDA, the authorized official certifies
that the above information is complete, true and accurate. Under 18 U.S.C. 1001, anyone who
makes a materially false, fictitious, or fraudulent statement to the U.S. Government is subject
to criminal penalties.
SIGNATURE:
PRINT NAME:
DATE
MM/DD/YYYY
Check the box on the left if you are submitting this form electronically, to signify that your
printed name will serve as your signature.
INSTRUCTIONS
You can download the form, fill it out, save it on your computer and e-mail it to:
menulawregistration@fda.hhs.gov
You can mail a completed copy to: FDA, HFS-681, 5600 Fishers Lane, Rockville, MD 20857.
Or you can Fax a completed form to (301) 436-2804.
Public reporting burden for this collection of information is estimated to average 2 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or another aspect of this collection of information, including suggestions for reducing this
burden to:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
1350 Piccard Drive, Room 400
Rockville, MD 20850
Please do NOT send this
form to this address
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid Office of Management and Budget (OMB) control number.
Form FDA 3757 (7/10)
Page 4 of 4
File Type | application/pdf |
File Title | Menu Labeling Registration Form |
Subject | U.S. Food and Drug Administration Menu Labeling Registration Form |
Author | FDA |
File Modified | 2010-07-20 |
File Created | 2010-06-09 |