6001 Recall

Organic Amaranth Flour Recall Form

Customer Name:*

Title:

Firm Name:*

Address: *

City: *

State:*

Zip: *

Phone:*

Area Code

Phone Number

E-mail:*

Please check ALL appropriate boxes:

I have read and understand the withdrawal instructions provided in the withdrawal notice.

I have checked my stock and I have no more remaining inventory subject to the withdrawal notice.

I have checked my stock and I have remaining inventory subject to the withdrawal notice.

I labeled, re-packed, reprocessed, or made new products that receive a thermal kill step that eliminates pathogens from my food. I will or have contacted the FDA Recall Coordinator in my state to verify (http://www.fda.gov/Safety/Recalls/IndustryGuidance/ucm129334.htm).

I labeled, re-packed, reprocessed, or made new products that did NOT receive a thermal kill step to eliminate pathogens from my food. I will or have contacted the FDA Recall Coordinator in my state as I may have to initiate my own recall (http://www.fda.gov/Safety/Recalls/IndustryGuidance/ucm129334.htm).

Number of Units Found:

Disposition of withdrawal product:

Returned

Destroyed

Quarantined for return or correction

Quantity returned, destroyed, or quarantined:

Date returned, destroyed, or quarantined:

day

month

year

Please describe the method used for returning or destroying product: