Products for Human Consumption Only
Certificate Request
Type of Request (Choose one)
*
Certificate of Free Sale
Free Sale Authorization
Business Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Product and Amount to be shipped
*
Do you need additional product/amount lines added?
Yes
No
Product and Amount to be shipped
Facility that Manufactured the Product
*
Facility's Permit Number
*
Notify Party
Business name or individual's first and last name
Where is the product going? (City, Country)
*
How many certificates do you need?
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How would you like to receive the certificates?
*
FedEx (Provide account number or attach waybill scan below)
Express Mail (DEC will add additional Express Mail Fee)
USPS Mail
In-person pickup
FedEx account number
FedEx Waybill scan
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name of who will be making payment
*
First Name
Last Name
Phone number of person making payment
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please verify that you are human
*
Submit
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