General Information About this Facility

Complete this form for EACH facility to be registered.(Copy this page for additional facilities) A “facility” is an establishment or structure that manufactures, processes, packs, or holds food that may be consumed in the USA by humans or animals.

Legal Company Name *

Legal Entity Type (such as SARL, S.A., BV, Ltd., etc.) *

DUNS Number

I am unaware of a DUNS number for my company and would like for Wild Coast Imports LLC to obtain a DUNS number on my behalf

Facility Street Address *

City *

State/Province/Region *

Postal Code *

Country *

Facility Telephone *

Email *

Website

List all Trade Names (e.g., “Also Doing Business As,” “Facility Also Known As”)

Emergency Contact Name: *

Title *

Contact’s Email *

Contact’s Mobile Phone: *

FDA Registration Number (11 digit number, no letters).

FDA PIN (PINs may include letters, numbers or symbols. Indicate if any letters are capitalized)

We searched but cannot find our registration or PIN.
Our facility is not currently registered with FDA.

Is your corporation (or other such entity) owned by a Parent Company or Group? *

If you selected “Yes” above, please provide your “Parent Company” information below (otherwise, leave the Parent Company fields blank). Parent Company Name (include legal entity type such as SARL, S.A., BV, Ltd., etc.)

Street Address

City

State/Province/Region

Postal Code

Country

Phone

Foreign Food Facility Registration & U.S. Agent for FDA Communications Services

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