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Date:02/16/2023 8:59:42
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Created Date Registration Expiration Date

2023-02-16 08:54:07.0 2024-12-31

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Is this facility engaged in the manufacturing/processing, packing, or holding of food for human or animal consumption in the United States?
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¡Yes ¤No
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Are you a broker, distributor, importer/filer?
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¡Yes ¤No
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Section 1: Type of Registration
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Facility Location: Foreign Registration
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UPDATE OF REGISTRATION INFORMATION:

Registration Number: 12683056874

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Are you the new owner of a previously registered facility?
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¡Yes ¤No
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Previous Owner's Title:
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Previous Owner's Name:
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Previous Owner's Registration Number:
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Section 2: Facility Name/Address Information
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Facility Name Telephone Number

DISMAPAN S A S 057 320 5161179

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Facility Name Suffix Fax Number
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Company
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Facility Street Address, Line 1 E-Mail Address
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CARRERA 52 36 41 comercioexterior@distribuidoradismapan.com
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Facility Street Address, Line 2 Unique Facility Identifier (UFI)
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City
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MEDELLIN
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State/Province/Territory
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Antioquia
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Zip Code (Postal Code)

050015
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COLOMBIA
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Section 3: Preferred Mailing Address Information

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Complete this section if different from Section 2 Facility Name/Address Information (OPTIONAL)
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Is the preferred mailing address the same as the facility address (Section 2)? Yes

Name Telephone Number

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DISMAPAN S A S 057 320 5161179

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Address, Line 1 Fax Number

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CARRERA 52 36 41
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Address, Line 2 E-Mail Address

comercioexterior@distribuidoradismapan.com
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City
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MEDELLIN
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State/Province/Territory

Antioquia
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Zip Code (Postal Code)
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050015

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COLOMBIA

Section 4: Parent Company Name/Address Information

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(If applicable and if different from Sections 2 and 3). If information is the same as another section, check which section:

¤Same as Facility Address (Section 2)

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¡Same as Preferred Mailing Address (Section 3)
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¡None of the above

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Company Name Telephone Number
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DISMAPAN S A S 057 320 5161179
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Company Name Suffix Fax Number

Company
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Address, Line 1 E-Mail Address
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CARRERA 52 36 41 comercioexterior@distribuidoradismapan.com
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Address, Line 2
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City
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MEDELLIN
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State/Province/Territory
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Antioquia

Zip Code (Postal Code)

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050015
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Section 5: Facility Emergency Contact Information

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If information is the same as another section, check which section:

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¤Same as Facility Address (Section 2)

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¡Same as U.S. Agent Information (Section 7)

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¡None of the above

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Individual's Title (Optional) Emergency Contact Phone

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057 320 5161179
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Individual's Name (Optional) E-Mail Address

comercioexterior@distribuidoradismapan.com
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Individual's Middle Name (Optional) Job Title (Optional)
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Individual's Last Name (Optional)

Section 6: Trade Names

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(If this facility uses trade names other than that listed in Section 2 above, list them below (e.g., "Also doing business as," "Facility also known as"))

Are there alternate trade names used by your facility in addition to the name provided in Section 2: Facility Name/Address Information?
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¤Yes
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¡No
Alternate Trade Name #1: mezclas express
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Section 7: United States Agent
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(To be completed by facilities located outside any state or territory of the United States, District of Columbia, or The Commonwealth of Puerto Rico)
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First Name Telephone Number
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ERICKA 770 8756773 null
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Middle Name (Optional) Emergency Contact Phone
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770 8756773
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Last Name Fax Number
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GIRALDO ATEHORTUA
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Title (Optional) E-Mail Address
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Address, Line 1
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3382 SWEETWATER DRIVE LAWRENCEVILLE
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Address, Line 2
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City
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Lawrenceville
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State/Province/Territory

Georgia
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Zip Code (Postal Code)

30044

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UNITED STATES
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Section 8: Seasonal Facility Dates of Operation (Optional)

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Give the approximate dates that your facility is open for business, if its operations are on a seasonal basis (Optional).
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Harvest 1
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Start Month End Month

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January December
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Harvest 2

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Start Month End Month
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Section 9: General Product Categories - Human/Animal/Both
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þFood for Human Consumption ¨Food for Animal Consumption
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Section 9a: General Product Categories - Food for Human Consumption; and Type of Activity Conducted at the
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Facility
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To be completed by Ambient Food Refrigerated Food Frozen Food Acidified Low- Interstat Contract Labeler / Manufact Packer / Salvage Farm Other
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all food facilities. Storage Warehouse Storage Warehouse Storage Warehouse Food Acid e Sterilizer Relabele urer / Repacke Operator Mixed- Activity

Please see / Holding Facility / Holding Facility / Holding Facility Process Food Conveya r Process r (Recondi Type Conduct
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instructions for (e.g., storage (e.g., storage (e.g., storage or Process nce or tioner) Facility ed
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further examples. IF facilities, including facilities, including facilities) or Caterer / (Please

NONE OF THE storage tanks, grain storage tanks) Catering Specify)

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MANDATORY elevators) Point
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CATEGORIES

BELOW APPLY,
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SELECT BOX 37
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3.BAKERY
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PRODUCTS,
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DOUGH MIXES, OR ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ þ þ ¨ ¨ þ
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ICINGS[21 CFR 170.3 (n)
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(1), (9)]

16.FOOD
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SWEETENERS
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(NUTRITIVE) [21 CFR ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ þ þ

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170.3 (n) (9) (41), 21 CFR 170.3
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(o) (21)]
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18.FRUIT OR

VEGETABLE JUICE,
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PULP OR
¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ þ þ ¨ ¨ þ
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CONCENTRATE

PRODUCTS[21 CFR
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170.3 (n) (3), (16), (35)]

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Other Activity Conducted

EXPORTER
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Section 10: Owner, Operator, or Agent-in-Charge Information

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Provide the following information, if different from all other sections on the form. If information is the same as another section of the form, check which
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section:
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If information is the same as Section 2, check the box:

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¤Section 2 - Facility Address Information

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¡Section 3 - Preferred Mailing Address Information

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¡Section 4 - Parent Company Address Information
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¡Section 7 - US Agent Address Information
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¡None of the above
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Name of Entity or Individual Who is the Owner, Operator, or Agent-in-Charge: DISMAPAN SAS
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Address, Line 1 Telephone Number
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CARRERA 52 36 41 057 320 5161179
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Address, Line 2 Fax Number
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City E-Mail Address

MEDELLIN comercioexterior@distribuidoradismapan.com
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State/Province/Territory
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Antioquia

Zip Code (Postal Code)

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050015
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COLOMBIA
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Section 11: Inspection Statement
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þFDA will be permitted to inspect the facility at the time and in the manner permitted by the Federal Food, Drug, and Cosmetic Act.
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