New Jersey Department of Health

Consumer, Environmental and Environmental Health Service

Food and Drug Safety Program

P.O. Box 369, Trenton, NJ 08625-0369

Telephone: 609-826-4935	Fax: 609-826-4990

www.nj.gov/health/foodanddrugsafety

Application FOR Certificate of Free Sale (CFS)	FOR STATE USE ONLY
Check/MO No.	______________

Amount

Tendered	$________________

Processor	________________

Date Rec’d	________________

Name of Company

NJDOH License or Registration Number

Street Address

Telephone Number

( )
City	State	Zip Code

Email Address (Required)

Is product listed on Certificate of Free Sale under embargo, seizure or other restraint?

Yes No

If yes, please explain. (Attach additional sheet, if necessary.)

If further verification/Apostille is required, please check below:

Mercer County Clerk’s Office or State Treasurer’s Office (must indicate country of destination)

Note: Refer to the Certificate of Free Sale Guidelines for the appropriate fees required.

For more information regarding this service and associated fees, please visit the Department of Treasury’s website at:

http://nj.gov/treasury/revenue/njbgs/gsfaq.shtml#apos2
The following information must be included on the Certificate of Free Sale (CFS) form:

1.)	Current date of inspection by the New Jersey Department of Health or the U.S. Food and Drug Administration (in the case of a Drug Company).

2.)	Type of establishment: Food, Drug or Cosmetic establishment.

3.)	Name under which establishment is licensed.

4.)	Location of licensed establishment where products are manufactured and distributed.

5.)	List of products to be certified.

6.)	Signature and notarization will be completed by the New Jersey Department of Health.
Additional Requirements:

1.)	The document must remain a single paged, typed document. HANDWRITTEN DOCUMENTS WILL NOT BE ACCEPTED.

2.)	Please include product labels for all products listed on the Certificate(s).

3.)	A certificate of analysis is required for all unfinished ingredients.

4.)	Pre-paid return postage is required.
Number of Products Per Certificate	Number of

Certificates Requested	X	Fee Per

Certificate	=	Total
CFS (3 or less items)	X	$50.00	=	$
CFS (4 through 9 items)	X	$75.00	=	$
CFS (10 through 25 items)	X	$100.00	=	$
Product G.M.P. Certificate	X	$50.00	=	$
General G.M.P. Certificate	X	$50.00	=	$
Sanitary Letter	X	$50.00	=	$
Export Certificate	X	$50.00	=	$
Health Certificate	X	$50.00	=	$
Total Number Enclosed:	Grand Total:	$
Important:	Enclose a separate check for the above Grand Total, made payable to the “NJDOH.” Any other checks, such as to the NJ State Treasurer or the Mercer County Clerk, must be separate checks.

Name of Applicant

Title

Signature

Date

Telephone Number

( )

F-12

JUL 12

F-12, Application for Certificate of Free Sale, (CFS)

F-12, certificate of free sale, food and drug safety, CFS

EWhite

2006-07-10

NJDOH