Customer Intake

Please note: This form collects information for your FDA cosmetic facility registration. It is not legal advice. Product listings (Form FDA 5067) are not included in this service.

A. Facility identity

Facility legal name (required)

DBA / trade names

Street address (required)

City (required)

State / province (required)

Postal code (required)

Country (required)

Facility email (required)

Facility phone (required) — include country code

FEI number — Leave blank if you don't have one — we will request it for you

D-U-N-S number

Owner / operator name (required)

Parent company name

Small-business facility?

YesNo

B. Brands

Please list each brand you manufacture. To add more brands (up to 10), click the "Add another brand" button below.

Brand 1

Brand name (required)

Responsible person name as on label (required)

Product category codes (required — select all that apply)

(01) Baby products(02) Bath preparations(03) Eye makeup (other than children's)(04) Children's eye makeup(05) Fragrance(06) Hair (noncoloring)(07) Hair coloring(08) Makeup (not eye)(09) Manicuring(10) Oral hygiene(11) Personal cleanliness(12) Shaving(13) Skin care(14) Suntan(15) Indoor tanning

Brand 2

Brand name

Responsible person name as on label

Product category codes (select all that apply)

Brand 3

Brand name

Responsible person name as on label

Product category codes (select all that apply)

C. U.S. agent

Your U.S. agent: US MoCRA Agent (GRABSHOP TRADING INDIVIDUALS LLC) — Phone: 909-997-0000 — Email: usmocra@outlook.com — Address provided in your service documents.

D. Authorized representative

Full name (required)

Title (required)

Relationship to facility (required)

Email (required)

Phone (required)

E. Documents

Optional. Accepted file types: PDF, JPG, PNG. Maximum 10 MB per file.

Business license / registration certificate

Proof of facility address

FEI assignment letter (if you have one)

F. Attestation

I am authorized to act for the facility, appoint a U.S. agent, and authorize FDA submissions on its behalf.

I appoint US MoCRA Agent as the facility's U.S. agent for MoCRA purposes, to be named on the FDA cosmetic facility registration (Form FDA 5066).

I authorize US MoCRA Agent to prepare and submit the facility registration, amendments, and biennial renewals through FDA Cosmetics Direct using the information I have provided and approved.

All information I have provided is true, complete, and accurate to the best of my knowledge.

I understand US MoCRA Agent is a private service provider, not affiliated with the FDA; is not a law firm; and does not provide product listings (Form FDA 5067), legal advice, product compliance, or GMP consulting.

I understand the FDA does not issue facility registration certificates and none will be provided.

I will promptly notify US MoCRA Agent of any change to the facility's name, address, contact information, or brands.

I understand the appointment lasts while my subscription is active and ends on cancellation, at which point US MoCRA Agent will formally resign and I must appoint a replacement agent to stay compliant.

Typed full name (required) — Type your full name as your signature

Date (required)

Review before you submit: Review every field carefully before submitting. You are responsible for the accuracy of this information — typos or errors can delay your FDA registration.

A. Facility identity

B. Brands

Brand 1

Brand 2

Brand 3

Brand 4

Brand 5

Brand 6

Brand 7

Brand 8

Brand 9

Brand 10

C. U.S. agent

D. Authorized representative

E. Documents

F. Attestation