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REGISTRATION APPLICATION FOR MANUFACTURER, PROCESSOR, REPACKAGER, OR WHOLESALE DISTRIBUTOR OF FOOD, DRUGS OR COSMETICS
State Form 13054 (R2 / 4-09) INDIANA STATE DEPARTMENT OF HEALTH FOOD PROTECTION PROGRAM

INDIANA FOOD, DRUG, AND COSMETIC ACT Indiana Code 16-42-1-6 REGISTRATION OF MANUFACTURER, PROCESSOR, WHOLESALE DISTRIBUTOR, ETC., MAINTAINING PLACE OF BUSINESS IN STATE Sec. 6. (a) A manufacturer, processor, repackager, or wholesale distributor of food, drugs, or cosmetics who maintains a place of business in Indiana shall file with the state department, upon forms to be furnished by the state department, a written statement of the name and address of the owner, the character of the business, and the business address of each place of business in Indiana. (b) A new business for the manufacture, processing, repacking, or wholesale distributor of food, drugs, or cosmetics may not be established in Indiana until the place of business has been registered as provided in this chapter. (c) If ownership of a registered place of business changes, the new owner shall register the place of business before operating the same. ************************************************************************ Date (month, day, year): _______________________ Name of Firm: _______________________________________________________________________________________ ____________________________________________________________________________________

Place of Business:

Owner: _______________________________________________________________________________________________ Type of Business: ____________________________________________________________________________________ _____________________________________________________________________

Products manufactured or processed:

Products distributed: ____________________________________________________________________________________ Products repackaged: ____________________________________________________________________________________ Products distributed at wholesale: _________________________________________________________________________ ________________________________________________ Applicant ________________________________________________ Title

RETURN COMPLETED FORM TO: Indiana State Department of Health Food Protection Program 5-C 2 North Meridian Street Indianapolis, IN 46204

FOR OFFICE USE ONLY: Registration Number: _____________________

Classification: _____________________