New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

P. O. Box 369

Trenton, NJ 08625-0369

INITIAL APPLICATION FOR LICENSE TO OPERATE

A NON-ALCOHOLIC BEVERAGE MANUFACTURING PLANT

(N.J.S.A. 24:15.2)	FOR STATE USE ONLY
ANNUAL FEE: $50.00

Complete all information. Mail original copy, with your fee, to the above address. Retain a copy for your records.

Make Check or Money Order payable to the “New Jersey Department of Health.”
Check/Money Order No.

Date of Check/Money Order

Amount

Date of Application

IDENTIFICATION
Name of Owner(s) or Corp.

Establishment Location

Trade Name

City

State

Zip Code

Telephone Number

Telephone Number (if different)

County Registered

If Incorporated, give Name of State

Federal ID / Social Security Number

PLANT TYPE

Non-Alcoholic Flavored Water Juice
NAMES AND ADDRESSES OF OFFICERS
President (Full Name)	Address	City	State	Zip Code

Vice-President (Full Name)	Address	City	State	Zip Code

Secretary (Full Name)	Address	City	State	Zip Code

Treasurer (Full Name)	Address	City	State	Zip Code

Other Officer (Full Name)	Address	City	State	Zip Code

Registered NJ Agent (If Applicable)	Address	City	State	Zip Code

CERTIFICATION

As the applicant or the authorized representative of the applicant,

I hereby certify that the foregoing statements are true to the best of my knowledge and belief.
Name and Title of Applicant

Signature	Date

F-9

JUL 12

F-9, Initial Application for License to Operate a Non-Alcoholic Beverage Manufacturing Plant

F-9, Consumer and Environmental Health, Initial Application for License to Opreate a Non-Alcoholic Beverage Manufacturing Plant,

EWhite

2012-03-28

NJDOH