DELAWARE HEALTH AND SOCIAL SERVICES
Division of Public Health


STATE OF DELAWARE

MATTRESS, PILLOW AND BEDDING PROGRAM
TITLE 16 DELAWARE CODE CHAPTER 21

APPLICATION FOR INITIAL PERMIT AND PERMIT RENEWAL
TO MANUFACTURE OR SHIP BEDDING PRODUCTS INTO DELAWARE 

Answer all questions and return to:	DPH HSP OFP
(Print legibly)			            417 FEDERAL ST
DOVER, DE  19901-3635	   Ph: 302-744-4546   Fax: 302-739-3839

1.   Legal name of business to appear on permit:

____________________________________________________________________________________

      Address to mail permit (include business name if different from above):

____________________________________________________________________________________

____________________________________________________________________________________

2.   Do you manufacture bedding products?	_____ YES* _____ NO

* If YES:  list physical location (City, State, Country) of bedding manufacturing sites:

____________________________________________________________________________________


3.   Do you distribute bedding products manufactured by others?	_____ YES* _____ NO

*If YES, list the Business Names and Locations of suppliers whose products you distribute.
       (Use extra sheets if needed.

____________________________________________________________________________________

4.   List types of bedding products shipped into Delaware:

____________________________________________________________________________________

____________________________________________________________________________________


Attach one (1) Law Label bedding tag with Uniform Registry Number (URN) - For both Initial and renewal.
	No permit will be issued without an original law label attached to application.  URN________________
	- Each different Uniform Registry Number requires a separate permit application and $50 fee.
	- Make additional copies of this application as needed.

Enclose check or money order in amount of $50.00 US payable to STATE OF DELAWARE

ATTENTION OVERSEAS COMPANIES:
Enclose money order or bank draft with US DOLLARS IMPRINTED ON THE MONEY ORDER OR BANK DRAFT.
Payments with hand-written US Dollar amounts cannot be accepted from outside U.S.    Check No.

Contact Information: (Please print legibly and sign in ink)

Name of person to whom permit will be sent:

Phone No & Extension__________________________________ Fax No.
Note:  This office cannot place telephone calls or send faxes outside U.S.

E-MAIL Address:

Date: __________________________    Signature of Applicant:

Applicant - Do not write below the dotted line

Date Approved: ____________  Date Permit Issued:_____________  Bedding Permit Number___________________

Signature of Official: _______________________________________  PAID STAMP:

Revised 9/2008			 Doc. # 35-05-20/08/10/26