DIRECTIONS FOR COMPLETION OF FSIS FORM 5200-2
Complete all sections. If a section is not applicable, enter "N/A" or "none". If additional space is needed for any item,
SECTION I. ESTABLISHMENT INFORMATION
1. Date of Application: Shall be the date on which the form is executed
2. Type of Application: Check applicable block
6. Address of Corporate Headquarters: Self-explanatory
7. Date Incorporated: Show month, day and year (i.e. mm/dd/yyyy)
5. State Where Incorporated: Self-explanatory
4. Form of Organization: Check applicable block
3. Type of Inspection Required: Check applicable block(s)
8. Name of Applicant and Mailing Address: Show official firm name and address
attach blueprint): Self-explanatory
16. Attach Limits or Establishment Premises to be Under Federal Inspection (for egg plants
15. Area Code and Telephone Number: Self-explanatory
14. Mailing Address (if different from item 8): Show the mailing address for the actual plant location
show location of the plant by street, number, miles from town or highway, etc
13. Actual name of and Physical Address of Plant: If the mailing address of item is a P.O. Box
12. Firm's Code (Import Only): Enter the company's Firm Code, if known
11. Area Code and Telephone Number: Self-explanatory
10. Dun & Bradstreet#: Enter D&B #
9. Federal Employer ID#: Enter Federal employee identification number
17. Name and Establishment Number of other official establishments located in the same facility:
21 B. Check the type of product intended for inspection at the establishment (check all that apply): Self-explanatory
b. - i. Check the type of product intended for inspection at the establishment (check all that apply): Self-explanatory
a. Check applicable blocks of animals to be slaughtered: Self-explanatory
21 A. Animals to be slaughtered when inspecting is inaugurated (meat and poultry only)
20. Comments: Insert any comments the applicant feels necessary
19. Month and Year when establishment will be ready to operate under inspection: Self-explanatory
applicant requesting inspection
18. Doing Business as: This refers to subsidiaries doing business under a different name than the
the same facilities of the applicant identified in item 8
Name of person(s) or firm name(s) and establishment number(s) which prepare products within
SECTION II. TYPE OF OPERATION
MEAT AND POULTRY INSPECTION ACTIVITIES
EGG PRODUCTS INSPECTION
22. a. - i. Check the types of products intended for inspection at the establishment (check all that apply): Self-explanatory
25. Persons Convicted of a Felony: Self-explanatory, if none, write none
provided concerning holding of stock.
directors, managers, or others in executive capacity. Be sure to show name, title, present home address and check in the block
26. Convictions against the Applicant: Self-explanatory
27. Sanitation Standard Operating Procedures have been developed for the establishment in accordance with 9 CFR 416.12
that will be used to deliver product intended for inspection to the establishment
23. Mode of Transportation - Import Inspection Only (Check all that apply): Check the blocks of the transportation methods
of the regulations: Check applicable box
21 C. Species (check all that apply): Check the block(s) of the species intended for inspection at the establishment
IMPORT INSPECTION
SECTION III. OWNERSHIP AND MANAGEMENT INFORMATION
24. List of Persons Responsibly Connected with the Applicant: Shall include person signing the application, owners, officers,
28. Privacy Act Notice: Check appropriate block
32. Is this establishment presently under state inspection (OFO Only): District Office will complete
36. Date: Self-explanatory
35. Signature of DM or IID Director: Self-explanatory
34. Official Inspection Number Reserved: District Office or Import Inspection Division - Headquarters will complete
33. Is this establishment to be under Talmadge-Aiken Act (OFO Only): District Office will complete
31. Title: Self-explanatory
30. Signature: Self-explanatory
29. Typed Name of Person Signing Application: Self-explanatory
attach a sheet and number the item.
