DHHS/FDA - FOOD FACILITY REGISTRATION FORM


Please review the registration.
DATE: 12/11/2003 03:16:01 PM (MM/DD/YYYY)

Section 1 - TYPE OF REGISTRATION
1a. Foreign Registration
1b. FACILITY REGISTRATION NUMBER: 17699596042 PIN: a9H9D6A4
1c. PREVIOUS OWNER'S NAME:
      PREVIOUS OWNER'S REGISTRATION NUMBER:

Section 2 - FACILITY NAME / ADDRESS INFORMATION
NAME: Merlini Riccardo S.P.A
FACILITY STREET ADDRESS, Line 1: Via Dell'Industria, 3
FACILITY STREET ADDRESS, Line 2: Sommacampagna
CITY: Verona
STATE / PROVINCE: Verona ZIP CODE (POSTAL CODE): 37066
COUNTRY: ITALY
PHONE NUMBER (Include Area/Country Code): 390 45 8960355
FAX NUMBER (OPTIONAL; Include Area/Country Code): 390 45 8960772
E-MAIL ADDRESS (OPTIONAL): lo_gnomo@iol.it

Section 3 - PREFERRED ADDRESS MAILING INFORMATION (Optional)
NAME:
ADDRESS, Line 1:
ADDRESS, Line 2:
CITY:
STATE / PROVINCE: ZIP CODE (POSTAL CODE):
COUNTRY:
PHONE NUMBER (Include Area/Country Code):
FAX NUMBER (OPTIONAL; Include Area/Country Code):
E-MAIL ADDRESS (OPTIONAL):

Section 4 - PARENT COMPANY NAME / ADDRESS INFORMATION
NAME OF PARENT COMPANY: Merlini Riccardo S.P.A
STREET ADDRESS, Line 1: Via Dell'Industria, 3
STREET ADDRESS, Line 2: Sommacampagna
CITY: Verona
STATE / PROVINCE: Verona ZIP CODE (POSTAL CODE): 37066
COUNTRY: ITALY
PHONE NUMBER (Include Area/Country Code): 390 45 8960355
FAX NUMBER (OPTIONAL; Include Area/Country Code): 390 45 8960772
E-MAIL ADDRESS (OPTIONAL): lo_gnomo@iol.it

Section 5 - FACILITY EMERGENCY CONTACT INFORMATION
INDIVIDUAL'S NAME (Optional):
TITLE (Optional):
EMERGENCY CONTACT PHONE (Include Area/Country Code):
E-MAIL ADDRESS (Optional):

Section 6 - TRADE NAMES
ALTERNATE TRADE NAME #1:
ALTERNATE TRADE NAME #2:
ALTERNATE TRADE NAME #3:
ALTERNATE TRADE NAME #4:

Section 7 - UNITED STATES AGENT
NAME OF U.S. AGENT: All-Ways Forwarding Int'l Inc
TITLE (Optional): All-Ways Forwarding Int'l Inc
STREET ADDRESS, Line 1: 701 Newark Avenue
STREET ADDRESS, Line 2: Suite 300
CITY: Elizabeth
STATE: NEW JERSEY ZIP CODE: 07208
U.S. AGENT PHONE NUMBER (Include Area Code): 908 3534000 202
EMERGENCY CONTACT PHONE (Include Area Code): 908 3534000
FAX NUMBER (OPTIONAL; Include Area Code): 908 3542000
E-MAIL ADDRESS (Optional): koneill@allwaysforwarding.com

Section 8 - SEASONAL FACILITY DATES OF OPERATION (Optional)
DATES OF OPERATION: Yearly

Section 9 - TYPE OF ACTIVITY CONDUCTED AT THE FACILITY (Optional)

Section 10 - TYPE OF STORAGE

Section 11a - GENERAL PRODUCT CATEGORIES - FOOD FOR HUMAN CONSUMPTION
Vegetables and Vegetable Products

Section 11b - GENERAL PRODUCT CATEGORY - FOOD FOR ANIMAL CONSUMPTION

Section 12 - OWNER, OPERATOR, OR AGENT IN CHARGE INFORMATION
NAME OF ENTITY OR INDIVIDUAL WHO IS THE OWNER, OPERATOR, OR AGENT IN CHARGE: Mr. Roberto Nicolato
STREET ADDRESS, Line 1: Via Dell'Industria, 3
STREET ADDRESS, Line 2: Sommacampagna
CITY: Verona
STATE / PROVINCE: Verona ZIP CODE (POSTAL CODE): 37066
COUNTRY: ITALY
PHONE NUMBER (Include Area/Country Code): 390 45 8960355
FAX NUMBER (OPTIONAL; Include Area/Country Code): 390 45 8960772
E-MAIL ADDRESS (OPTIONAL): lo_gnomo@iol.it

Section 13 - 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, or by authorizing an individual to submit this form to FDA, the owner, operator, or agent in charge of the facility certifies that the above information is true and accurate. An individual (other than the owner, operator or agent in charge of the facility) who submits the form to the FDA also certifies that the above information submitted is ture and accurate and that he/she is authorized to submit the registration on the facility's behalf. An individual authorized by the owner, operator, or agent in charge must below identify by name the individual who authorized submission of the registration. Under 18 U.S.C 1001, anyone who makes a materially false, ficticious, or fraudulent statement to the U.S. Government is subject to criminal penalties.
NAME OF THE SUBMITTER: Kelly O'Neill
CHECK ONE BOX:
IF YOU CHECKED BOX B ABOVE, INDICATE WHO AUTHORIZED YOU TO SUBMIT THE REGISTRATION:
 OWNER, OPERATOR OR AGENT IN CHARGE
 __________________ (INDIVIDUAL AUTHORIZED TO SUBMIT THE REGISTRATION)
FACILITY STREET ADDRESS, Line 1:
FACILITY STREET ADDRESS, Line 2:
CITY:
STATE / PROVINCE: ZIP CODE (POSTAL CODE):
COUNTRY:
PHONE NUMBER (Include Area/Country Code):
FAX NUMBER (OPTIONAL; Include Area/Country Code):
E-MAIL ADDRESS (OPTIONAL):