Fda 766 Application For Authorization To Relabel Or To Perform O

SUBMIT IN TRIPLICATE (Submit in QUADRUPLICATE if you desire copy returned to you.)

APPLICATION FOR AUTHORIZATION TO RELABEL OR TO PERFORM OTHER ACTION
OF THE FEDERAL FOOD, DRUG, AND COSMETIC ACT AND OTHER RELATED ACTS
Public reporting burden time for this collection of information is estimated to average .25 hour per
response, including the time to review instructions, search existing data sources, gather and maintain
the data needed and complete and review the collection of information. Send comments regarding this
burden estimate or any other aspect of this information collection, including suggestions for reducing
this burden, to the address to the right:

DIRECTOR
Food and Drug Administration

DATE

Division,

EXPIRATION DATE: 7/31/2020

Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
Paperwork Reduction Act (PRA) Staff
PRAStaff@fda.hhs.gov
Please do NOT send your completed form to
the above PRA Staff email 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 OMB control number.
TO:

FORM APPROVED: OMB No. 0910-0025

SAMPLE NO.

PRODUCT

Application is hereby made for authorization to bring the
merchandise below into compliance with the Act.

ENTRY NO.

CARRIER

ENTRY DATE

AMOUNT AND MARKS

Redelivery bond has been posted by the applicant. The merchandise will be kept apart from all other merchandise and will
be available for inspection at all reasonable times. The operations, if authorized, will be carried out at:
and will require
days to complete. A detailed description of the method by which the merchandise will be brought into
about
compliance is given in the space below:

We will pay all supervisory costs in accordance with current regulations.
FIRM NAME

ADDRESS OF FIRM

APPLICANT’S SIGNATURE

ACTION ON APPLICATION
TO: (Name and Address)

Your application has been:

DATE

Denied because:

Approved with the following conditions:

Time limit within which to complete authorized operations:
When the authorized operations are completed, fill in the importer’s certificate on the reverse side and return this notice to
this office.
SIGNATURE OF DIVISION DIRECTOR

FORM FDA 766 (01/18)

DIVISION

(See Back)

DATE

FRONT
PSC Publishing Services (301) 443-6740

EF

IMPORTER’S CERTIFICATE
PLACE

DATE

I certify that the work to be performed under the authorization has been completed and the goods are now ready
for inspection at:
.
The rejected portion is ready for destruction under Customs’ supervision and is held at:
.
TYPED NAME OF APPLICANT

SIGNATURE

REPORT OF INVESTIGATOR / INSPECTOR
TO

DATE

PORT DIRECTOR OR DIVISION DIRECTOR

I have examined the within-described goods and find them to be the identical goods described herein, and that
they have been:
on:
, 20
as authorized, except:

,

DATA ON CLEANED GOODS
Good Portion:
Rejections:
Loss (if any):
Did importer clean
entire shipment?
Time and cost of
supervision:
INSPECTING OFFICER

DATE

DIVISION DIRECTOR

Disposed of as noted above.
DIRECTOR OF CUSTOMS

FORM FDA 766 (01/18)

DATE

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