Application For Registration Of Antifreeze Form - Florida Department Of Agriculture And Consumer Services

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Florida Department of Agriculture and Consumer Services
Remit $200 Non-Refundable
Application Fee Online at:
Division of Consumer Services, Bureau of Standards
- or -
APPLICATION FOR REGISTRATION OF ANTIFREEZE
Check or Money Order payable
J
1, ____
J
30, ____
ULY
THROUGH
UNE
to FDACS and remit to:
FDACS
ADAM H. PUTNAM
Section 501.913, Florida Statutes
P.O. Box 6700
COMMISSIONER
Rule 5J-23.0015, Florida Administrative Code
Tallahassee, FL 32314-6700
________________________________________________________________________
Brand Name
____________________________________________
(___)____________________
Applicant
Phone
___________________________________________________________________________
Address
_____________________________________________
________
________________
City
State
ZIP
_____________________________
Formula
Applicant is (check all that apply): □ manufacturer, □ packager, □ name that appears on the label.
Specifications (check all that apply; brand will be required to meet all specifications checked):
□ D3306; □ D3306 mod (see 5J-23.001(1)(a),F.A.C.); □ D7518; □ D4985; □ D 6210; □ D7517; □ D6471; □ D6472
□ D7714; □ D7715.
Container sizes to be marketed: Gallon ___ 55 Gal Drum ___ Quart ___ Other ___________
Do NOT send sample product to Post Office Box listed above.
See page 2, Antifreeze Registration Instructions, for proper shipping address.
Applicant certifies that the sample submitted is representative of the product to be sold and that it
meets the requirements of Sections 501.91-501.923, F.S., and Rule Chapter 5J-23, F.A.C.
___________________________
__________________________
______________________
(Signature)
(Please print name)
(Title)
________________________________________________
______________________
(E-mail)
(Date)
Please see page 2 for instructions.
(For official use only)
LIMS # ___________________
Date Denied
Date Registered
Code
Permit #
Permit Date
Comments:
_____________________________________________________________________________________
___________________________________________________________________________________________________
Org Code: 42 10 09 01 000
EO: A2
Object Code: 001019
FDACS-03211 Rev. 11/13
Page 1 of 2

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