NSF/ANSI 455 Application Form
Please complete this form and return to your NSF contact to receive a formal proposal.
Corporate Information Completed by: Click here to enter text. Date: Click for date.
Corporate Legal Name: Click here to enter text. Primary Contact Name: Click here to enter text.
Address: Click here to enter text. Title: Click here to enter text.
Website: Click here to enter text. Phone: Click here to enter text.
Mainf Phone: Click here to enter text. Email: Click here to enter text.
a Information
Billing
l
s Check box, if billing information is the same as above. Contact: Click here to enter text.
e (if different from above):
Address Phone: Click here to enter text.
Click here to enter text. Email: Click here to enter text.
Referral of scope of certification
Amazon Topco Walgreens Walmart Wegmans Watson
Whole Foods Decline to disclose Other: Click here to enter text.
Scope of Certification
Certification Program:
NSF 455 Certification Program GRMA Certification Program
Audit Standards (Check all that apply): Additional Scope (Check all that apply):
NSF/ANSI 455-2 Dietary Supplements Dietary Supplements Product Certification
NSF/ANSI 455-3 Cosmetics (Personal Care) GMP for Sport (Dietary Supplements only)
NSF/ANSI 455-4 Over-the-Counter Drugs CBD/Hemp is out of scope for OTC Drugs
GRMA Site Type: Choose an item.
Besides what is selected above, do you manufacture other products?
No Yes, other products: Click here to enter text.
Have you initiated or have NSF/ANSI 455 certification with another Certification Body (CB)?
Yes No. If Yes, state CB Click here to enter text.
Document #: 29189; Revision: 02; Status: Release; Release Date: 06 Apr 2022; Printed on: 31 Dec 2024
This is a confidential document and may be reproduced only with the permission of NSF. Page 1 of 4
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NSF/ANSI 455 Application Form
Please complete this form and return to your NSF contact to receive a formal proposal.
Facility Information Number each Facility on this document:
Facility Legal Name: Click here to enter text. Primary Contact Name: Click here to enter text.
Address: Click here to enter text. Phone: Click here to enter text.
Main Phone: Click here to enter text. Email: Click here to enter text.
Audit / Additional Contacts:
Contact Name: Click here to enter text. Contact Name: Click here to enter text.
Email: Click here to enter text. Email: Click here to enter text.
Site Type: Choose an item.
No. of buildings at this address: Enter text Total Facility Size: Enter text
Days of Operation: Enter text Number of Shifts: Choose an item.
Choose an item.Total number of Enter text Laboratory: Choose an item. Choose an item.Choo
employees: se an item.
Choose an item.Primary Facility Language:
Click here to enter text. Primary Document Language Click here to enter text.
Product Technology/Key Manufacturing Stages operational at this facility with Active or Inactive status (click all that apply):*
Dietary Supplements Cosmetics OTC Drugs
Product Technology
(NSF/ANSI 455-2) (NSF/ANSI 455-3) (NSF/ANSI 455-4)
Baking
Coating
Dry Formulation
Encapsulation
Enrobing
Kits
Liquid Formulation
Mixing
Molding
Packaging/Labeling Operation
Bulk Packaging
Primary Packaging
Secondary Packaging
Dispensing
Quality Unit Operations
Sterilization
Tablet Compression
Warehousing
Other: Click here to enter text. Click here to enter text. Click here to enter text.
Product Categories / Product Types operational at this facility with Active or Inactive status (Click all that apply):*
Document #: 29189; Revision: 02; Status: Release; Release Date: 06 Apr 2022; Printed on: 31 Dec 2024
This is a confidential document and may be reproduced only with the permission of NSF. Page 2 of 4
NSF Confidential
NSF/ANSI 455 Application Form
Please complete this form and return to your NSF contact to receive a formal proposal.
Dietary Supplements (NSF/ANSI 455-2) Cosmetics (NSF/ANSI 455-3) OTC Drugs (NSF/ANSI 455-4)
Capsule ✘ Aerosols Aerosols
Gummy Aromatic Anti-Perspirant
Ingestible Liquid ✘ Balm/Gloss Capsule
Ingestible Oil Beauty Aid Cream
Oral, Dissolving Films Facial masks Gel
Powder Primer Lozenge
Soft Gel Cake Oral, Dissolving Films
Tablet Cleanser Powder(s)
Other: Deodorant Soft Gel
Click here to enter text. Eyewear (Ocular Cavity) Sprays
Eyebrow pencils, creams, waxes, gels, Solution
and powders Sterile
Eyeliner Non-Sterile
Eyeshadow Contact Lens Cleaner
False eyelashes Sunscreen
Highlighter Suppositories
Mascara Suspensions
Primers Sterile
Gel Non-sterile
Lipstick, Gloss, and Balm (Oral Cavity) Tablet
Liquid Toothpaste
Moisturizer, Lotion, and Cream Trans-Dermal Patch
Oil Wipes
Oral Films and Strips Other:
Personal Care (includes shampoo, body Paste
wash, other soap)
Body washes and Shower gels
Hair conditioner
Shampoo
Soaps
Powder
Serum
Toner
Toothpaste and Gel
Wipes
Other:
Click here to enter text.
Do any selected product categories above contain water as an ingredient? Yes No *GRMA Scheme definitions
Exclusions from the scope of certification:
Per 5.3.4 of the NSF/ANSI 455 Standard, exclusion of products is acceptable only where
1) the excluded products can be clearly differentiated from the products in scope, and
Document #: 29189; Revision: 02; Status: Release; Release Date: 06 Apr 2022; Printed on: 31 Dec 2024
This is a confidential document and may be reproduced only with the permission of NSF. Page 3 of 4
NSF Confidential
NSF/ANSI 455 Application Form
Please complete this form and return to your NSF contact to receive a formal proposal.
2) those products are produced in a physically segregated area of the site.
3) Products under development and/or under trial production, or both, are excluded from the scope of the audit.
Are there any product technologies listed above that you request to exclude from the scope of certification?
No Yes, product technologies: Click here to enter text.
Are there any product categories listed above that you request to exclude from the scope of certification?
No Yes, product categories: Click here to enter text.
Are there any product technology and/or product categories listed above under development and/or under trial production, or both?"
No Yes, product technologies or categories: Click here to enter text.
Brands and lots cannot be excluded from scope of certification.
Additional Associated Site Location Information:
Please enter information for each additional site address in close proximity (typically within 15 minutes) to be included in the NSF/ANSI 455 audit.
Not Applicable.
Additional Sites.
Then click the plus sign on the bottom right corner of the table to provide detailed information. Repeat this process at the end of the facility
information for each additional site with a different address.
Document #: 29189; Revision: 02; Status: Release; Release Date: 06 Apr 2022; Printed on: 31 Dec 2024
This is a confidential document and may be reproduced only with the permission of NSF. Page 4 of 4
NSF Confidential
