(Date) _______________________________
Dockets Management Staff, Food and Drug Administration, Department of Health and Human Services, 5630 Fishers Lane, rm. 1061, Rockville, MD 20852.
Petition for Stay of Action
The undersigned submits this petition requesting that the Commissioner of Food and Drugs stay the effective date of the following matter.
(The specific administrative action being taken by the Commissioner for which a stay is requested, including the docket number or other citation to the action involved.)
(The length of time for which the stay is requested, which may be for a specific or indefinite time period.)
(A full statement, in a well-organized format, of the factual and legal grounds upon which the petitioner relies for the stay.)
(Signature) _______________________________
(Name of petitioner) _______________________________
(Mailing address) _______________________________
(Telephone number)_______________________________
21 C.F.R. §10.35