Firm Number
Appendix I -- Model Small Business Food Labeling Exemption Notice
(Please type or clearly print in blank spaces; make any necessary changes to the typed firm name/address)
1.	Name of Firm	_______________________________________________________________________
2.	Address of Firm
	Street Address	_______________________________________________________________________
	City	___________________________________ State____________ Zip/Postal code__________
	Country	_________________________________________
	Telephone	_________________________________ Fax ___________________________________
	E-mail	_______________________________________________________________________
3.	Type of Firm (Check all that apply)
	Manufacturer __________________ Packer/Repacker __________________ Retailer __________________
	Distributor __________________ Importer __________________
4. Twelve-month time period for which you are claiming exemption   From: _05_ / _08_ / _2002_ To: _05_ / _07_ / _2003_     MM   DD   YY   MM   DD   YY
5.	Average number of full-time equivalent employees for 12 month period ___________________
6.	Report of units sold (Use continuation sheet if necessary)
Product No. of Units Manufacturer ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________
7.	Name and address of manufacturer(s) or distributor(s) of product(s) in item 6 if different from firm claiming exemption. (Use continuation sheet if necessary.)
_B_ Name of manufacturer or distributor __________________________________________________   Address __________________________________________________ _C_ Name of manufacturer or distributor __________________________________________________   Address __________________________________________________
8.	Contact Person _______________________________________________________
9.	The undersigned certifies that the above information is a true and accurate representation of the operations of ________________________________________________________________________ (Name of Firm)
The undersigned will notify the Office of Nutritional Products, Labeling and Dietary Supplements of the date on which the average number of full-time equivalent employees or the number of units food products sold in the United States exceeds the applicable number for exemption which is being claimed herein.
Signature ____________________________________________________________________________ Name (Type or clearly print) ______________________________________________________________ Title ________________________________________________________________________________ Date ________________________________________________________________________________

Form Introduction
Instructions for Completing Form

Hypertext updated by ear/cjm 2002-JUN-07