1070 Mail Service Center, Raleigh, North Carolina 27699-1070 ⚫ (919) 733-7366 ⚫ Fax (919) 733-6801
Agent
Firm
Name*
Agent Mailing Address*
City
State Postal Code
Country
Agent Primary Contact Name*
Agent Primary Phone Number & Extension*
Agent Primary Email Address*
*required field
North Carolina Food & Drug Protection Division
Animal Feed Program
NEW AGENT RELATIONSHIP ACCOUNT INFORMATION FORM
Please provide contact information in order to keep our records current. This form is for
AGENT information only, meaning if product registration is managed or submitted by a 3rd
party agent, registrant, etc. Contact information for the AGENT must be provided to include
Primary Contact name, phone number, and email address in order to complete the
registration process.
Please provide AGENT information.
