1070 Mail Service Center, Raleigh, North Carolina 27699-1070 ⚫ (919) 733-7366 ⚫ Fax (919) 733-6801
North Carolina Food & Drug Protection Division
Animal Feed Program
NEW MANUFACTURER/FIRM ACCOUNT INFORMATION FORM
Please provide contact information in order to keep our records current. This form is for
FIRM information only, meaning the Manufacturer and/or Guarantor legally responsible
for the products. The information on this form should NOT include any contact information
for 3rd party agents, registrants, etc. If product registration is managed by an agent other
than the FIRM, please complete “New Agent Relationship Information Form” to submit
contact information for 3rd party agents, registrants, etc. in addition to this form in order
to complete the registration process.
Please provide FIRM information only.
Firm Nam
e*
Physical Address*
City State Postal Code County Country
Main Phone Number* Website
Firm Mailing Address □ Check if information is same as above
City State Postal Code County Country
Firm Primary Contact Name* Firm Primary Contact Phone Number & Extension*
Firm Primary Contact Email Address*
*required field
