Check/MO No. Telephone: 609-826-4935 Fax: 609-826-4990 ...

1 F-12 JUL 12 FOR STATE USE ONLYNew jersey Department of HealthConsumer, Environmental and Environmental Health ServiceFood and Drug Safety Box 369, Trenton, NJ 08625-0369 Telephone: 609-826-4935 Fax: FOR certificate OF free SALE (CFS) Check/MO No. _____AmountTendered$_____Processor_____D ate Rec d_____Name of Company NJDOH License or Registration Number Street Address Telephone Number( ) CityStateZip Code Email Address (Required) Is product listed on certificate of free Sale under embargo, seizure or other restraint? Yes NoIf 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 more information regarding this service and associated fees, please visit the Department of Treasury s website at: #apos2 The following information must be included on the certificate of free Sale (CFS) form:1.

2 Current date of inspection by the New jersey Department of Health or the Food and Drug Administration (in the caseof a Drug Company).2.) Type of establishment: Food, Drug or Cosmetic ) Name under which establishment is ) Location of licensed establishment where products are manufactured and ) List of products to be ) Signature and notarization will be completed by the New jersey Department of Requirements:1.) The document must remain a single paged, typed document. HANDWRITTEN DOCUMENTS WILL NOT BE ) Please include product labels for all products listed on the certificate (s).3.) A certificate of analysis is required for all unfinished ) Pre-paid return postage is of Products Per CertificateNumber ofCertificatesRequestedXFee PerCertificate=TotalCFS (3 or less items) X$ $ CFS (4 through 9 items) X$ $ CFS (10 through 25 items) X$ $ Product certificate X$ $ General certificate X$ $ Sanitary Letter X$ $ Export certificate X$ $ Health certificate X$ $ Total Number Enclosed: Grand Total:$ IMPORTANT.

3 Enclose a separate check for the above Grand Total, made payable to the NJDOH. Any otherchecks such as to the NJ State Treasurer or the Mercer County Clerk must be separate of Applicant Title Signature Date Telephone Number( ) F-L4 JUL 12 DEPARTMENT OF HEALTHCONSUMER, ENVIRONMENTAL AND OCCUPATIONAL HEALTH SERVICEPO BOX 369 TRENTON, OF free SALEPOR ESTE MEDIO certificamos que una inspecci n hecha el _____ por un representante de este Departamentode las condiciones sanitarias de este _____ establecimiento de manufactura de_____ en _____revel que dicho establecimiento establa en condiciones sanitarias adecuadas y ha estado funcionando de acuerdo con las leyesvigentes por este ADEM S POR ESTE MEDIO CERTIFICADO que los siguientes producto(s).

4 Manufacturados por _____, est nrotulados conforme a las leyes de alimentos, drogas y cosm ticos del estado de New jersey y son vendidos en este estado y a losdem s estados de los Estados Unidos de Norte Am ES PARA USO DEL ESTADOS ubscrito y jurado ante mi este_____ d a de _____, P blico del Estado de New JerseyMI COMISI N EXPIRE: V LIDO SIN ES SELLO OFICIAL DEL NOTARIO P BLICO NOMBRADO AQU