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Section 13A : Certification Statement

Certification Statement

The owner, operator, or agent in charge of the facility, or an individual authorized by the owner, operator, or agent in charge of the facility, must submit this form. By submitting this form to FDA, the owner, operator, or agent in charge or the individual authorized by the owner, operator, or agent in charge, certifies that the information submitted is true and accurate and that the facility has authorized the submitter to register on its behalf. 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.

*I understand the above statement.

*I verify that the information to be submitted is true.

*I authorize RegisterFDA.com to register my submitted information to FDA

*I agree to, and understand RegisterFDA's Terms and Conditions

*Name of person submitting this registration form:

You are the Owner, Operator, or Agent in Charge

You are an Individual Authorized to Submit the Registration

*Name of Authorizing Individual, or yourself if you are the Owner, Operator, or Agent in Charge:

Address of the Authorizing Individual, or yourself if you are the Owner, Operator, or Agent in Charge:

Address is the same as the facility address. (Section 2)

Address is the same as the preferred mailing address. (Section 3)

Address is the same as the parent company address. (Section 4)

Address is the same as the owner, operator, or agent in charge. (Section 11)

The Authorizing Individual is best contacted at a different address.

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