Contact Name

Company Name

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Email

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Product Name(s)

Product Type (Check one) Product Type (Check one) Packaged Grocery Refrigerated or Frozen Supplements or Bodycare Bulk Foods Baked Goods Meat Produce Other

Product Details (Check all that apply) Product Details (Check all that apply) Have Individual UPC/barcode Have Printed Nutrition Information Have Printed Allergen Information Produced in New York Organic Other

Other Product Details

Up-to-Date Documents & Permits (Check all that apply) Up-to-Date Documents & Permits (Check all that apply) Proof of Insurance ($1 million) Food Manufacturing License Permit to Operate a Food Service Establishment Food Manager’s Certification Sales Tax Permit Organic Certificate Other

Other Documents & Permits

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