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Form for Requesting:

Product Testing and
Nutritional Facts Panel

Thank you for your interest in the entrepreneurial assistance program at NC State University. Your products are very important to us. Thank you for making NC State's food entrepreneurial assistance program one of the strongest in the nation.

Please fill out the following form and submit on-line. In fairness to all clients, we respond in the order that we receive requests. If you are requesting a product to be tested, we will contact you with information on mailing your samples.

In order to make the process work more efficiently you MUST select one of the following:

I only want my product tested. ($100 per product)

I only want a Nutritional Facts Panel prepared for my product. ($100 per product)

I would like my product tested and a Nutritional Facts Panel prepared. ($200 per product)

If you are having a product tested, wait and send payment with the product. If you are only having a nutritional facts panel prepared, please send payment when you have submitted this form. Make check or money order payable to: NCSU Food Science

Address:	Dr. Fletcher Arritt
	400 Dan Allen Drive
	129 Schaub Hall Box 7624
	North Carolina State University
	Raleigh, NC 27695-7624

If you would like to pay by credit card please list the following:

Type 'Yes' in this box:

A preferred phone number

Best time of day to be contacted at preferred phone number (i.e. Morning, Afternoon, Evening)

Someone from our office will contact you at the preferred phone number to obtain your credit card information.

If you have any questions or need assistance with this form, you may contact us at 919.513.2090.

Tip: Use the tab key, not the enter key, to navigate through the form. Hitting the enter key will submit your form.

Last modified: November 16, 2012

Name:

Address:
City:		State:
Zip:

Phone number:
Additional Phone number:
E-mail Address:

Company Name:
Name of Product (such as "barbeque sauce")
Product Description (such as "dried herbs in mayonnaise and cream cheese")

Note:	Please give complete information.
	Including brand names of ingredients is helpful.
	Take very accurate weights and/or measurements of each ingredient. These amounts should be for a complete batch as it is prepared. Do not do conversions.
	If you are listing weights of ingredients, you should use an accurate scale. If you are using a whole container of another product as an ingredient, you can obtain the content weight from that label. Do not confuse fluid ounces (8 fl. oz. in a cup) with weight ounces (16 ounces in a pound). They are not the same!

	Ingredient	Amount (i.e. 1 gram) Weight or Volume (you must fill this in)	Form raw, dried, frozen, powder, bottled, canned, etc.	Other explanation If you chose "other" in the Form column or cannot find a default term in the Amount field please explain here.
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Please answer the following questions:

1. What is the net weight or volume (oz. or fl. oz.) of product in the container you will be selling?
2. Is your product cooked? Yes No
3. Please give a brief description of how you process your product.

4.Will you be processing and packaging this product or will you be using a co-packer? If a copacker, which one?

5.Have you attended an acidified foods course(i.e. Better Process Control School)? If so, when and where? Yes No
It is not required for you to take the acidified food course if you working with a copacker.

Before submitting this form please make sure that you have included all of the ingredients, number of ingredients, amount, form, and explanation (if needed) for all parts of your product. Failure to do so will only delay the processing of your request submission.