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(Meat, Poultry, Egg Product and Import Inspection) APPLICATION (Information Technology Services)

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17. Name and Establishment Number of other official
establishments located in the same facility
19. Month and Year when establishment will be ready to operate under inspection
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0153. The time required to complete this information collection is
estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.
4. Form of Organization (Check box)
3. Type of Inspection Required (Check box)
U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE
APPLICATION FOR FEDERAL INSPECTION
(Meat, Poultry, Egg Product and Import Inspection)
Instructions: Submit this application to the District/Regional Office, Food
Safety and Inspection Service, U.S. Department of Agriculture for import
inspection requests. Complete all sections. If a section is not applicable,
enter "N/A" or "None." If additional space is needed for any item, attach
sheet and number the item.
SECTION I.
ESTABLISHMENT INFORMATION
2. Type of Application
New Change of Ownership Change of Location Application Extension
ImportEgg Product
Poultry
Meat
Corporation
Partnership
Cooperative Association
Individual
LLC
5. If Corporation, Name of State Where Incorporated
1. Date of Application
6. Address of Corporate Headquarters
8. Name of Applicant and Mailing Address (include zip
code)
9. Federal Employer ID#
10. Dun & Bradstreet # (if applicable)
11. Area Code and
Telephone Number
13. Actual Name of and Physical Address of Plant
14. Mailing Address if Different from Item 8 (include zip code)
15. Area Code and
Telephone Number
16. Attach Limits or Establishment Premises to be under Federal Inspection (for egg plants attach blueprint)
18. Doing Business As
20. Comments
MEAT AND POULTRY INSPECTION ACTIVITIES (Check all that apply.)
SECTION II.
Animals to be slaughtered when inspecting is inaugurated (meat and poultry only)
Guineas
Squab
Ratites
TYPE OF OPERATION
Beef Sheep Goats Swine Equine Chicken Turkeys DucksGoose
FSIS Form 5200-2 (4/03/2013)
21 A.
7. Date Incorporated
12. Firm's Code (Import
Only)
a..
Raw - Intact Products
Raw - Non-Intact Products
b.
Not Heat Treated - Shelf Stable
e.
Thermally Processed Commercially Sterile
c.
d.
Heat Treated but Not Fully Cooked - Not Shelf Stable
Heat Treated - Shelf Stable
f.
h.
Fully Cooked - Not Shelf Stable
g.
Product with Secondary Inhibitors - Not Shelf Stable
i.
PREVIOUS EDITONS ARE OBSOLETE
FSIS Form 5200-2 (4/03/2013) Page 2
Cans/Pails Flexible Pouches Jars Cartons Bag-n-Box Totes Tankers
Shell Egg Breaking
a.
Thermally Processed (Pasteurized heat treated)
b.
Not Heat Treated - Unpasteurized egg product only
c.
Heat Treated - Shelf Stable (Dried egg product, 50% Sugar Yolk)
d.
Heat Treated But Not Fully Cooked - not shelf stable (liquid and frozen egg products)
e.
21 B.
Other
Check the type of product intended for inspection at the establishment (Check all that apply)
EGG PRODUCTS INSPECTION
Meat
21 C.
Species (Check all that apply)
IMPORT INSPECTION
Poultry
Egg Products
Check the type of product intended for inspection at the establishment (Check all that apply)
22.
Thermally Processed Commercially Sterile
Raw - Intact
b.
Heat Treated - Shelf Stable
e.
Not Heat Treated - Shelf Stable
c.
d.
Heat Treated But Not Fully Cooked - Not Shelf Stable
Shell Eggs/Egg Products
i.
g.
Fully Cooked - Not Shelf Stable
f.
Product with Secondary Inhibitors - Not Shelf Stable
h.
Raw - Non-Intact
a.
Ground
Other Non-Intact
Veal
Hide On
Veal
Ratites
Beef Goats Pork
Equine PoultryMutton
Lamb
Cuts
Carcasses:
Other: Boneless Manufacturing Meats Other Intact
JarsFlexible Pouches TraysCans
Frozen from an APHIS restricted country (9CFR 94.4(b)) Frozen Perishable
FrozenLiquidShell Eggs Dried
Mode of Transportation - Import Inspection Only (Check all that apply)
23.
Trucks
Rail CarsTankers Ocean Vessel Airline
Other (Specify)
FSIS Form 5200-2 (4/03/2013) Page 3
33. Is this establishment to be under Talmadge-Aiken Act? (OFO only)
28. Applicant has been provided with a copy of this Privacy Act Notice. (Check one)
SECTION III OWNERSHIP AND MANAGEMENT INFORMATION
24. List all persons responsibly connected with the applicant. Include all owners, partners, officers, directors, holders or owners of 10 per centum or
more of voting stock and employees in a managerial or executive capacity in the business. Notify the Division Director or import Inspection Division
Director of any changes in the listing given.
YES
NO
Name and Title
(Title - Indicate if partner or manager)
Present Home Address
(Street and Number, City, State, Zip Code)
25. Enter the name of each person listed under Item 24 who has been convicted in any Federal or State court of any felony. Enter the name of each
person listed under item 24 who has been convicted in any Federal or State court of more than one violation of any law, other than a felony, based
upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or upon fraud in connection with transactions in
food. Include the nature of the crime, the date of conviction and the court in which convicted. If none write "None."
26. List each conviction against the applicant (person, firm or corporation) in any Federal or State court of any felony, List each conviction against the
applicant (person, firm or corporation) in any Federal or State court of more than one violation of any law, other than a felony, based upon the
acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or upon fraud in connection with transactions in food.
Include the nature of the crime, the date of conviction and the court in which convicted. If none write "None."
HOLDER OF 10% OR
MORE VOTING STOCK
(If Corp.)
27. Have conditions for receiving inspection been met (HACCP, SSOP, Recall Procedures) in accordance with 304.3 and 381.22 of the regulations.
(Check one)
§
NOYES
NOYES
29. Typed Name of Person Signing Application
30. Signature 31. Title
32. Is this establishment presently under State inspection or the Cooperative Interstate Shipment (CIS) Program?
TO BE COMPLETED BY USDA, FSIS
NOYES
NOYES
36. Date
35. Signature of DM or IID Director34. Official Inspection Number Reserved
CISSTATE
27. Have conditions for receiving inspection been met (HACCP, SSOP, Recall Procedures) in accordance with 304.3 and 381.22
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 # (if applicable)
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
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
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 or the Cooperative Interstate Shipment (CIS) Program?
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.
of the regulations. Check one
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(Meat, Poultry, Egg Product and Import Inspection) APPLICATION (Information Technology Services)

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Completed 14 August 2020

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