APPLICATION FOR FSIS Form 7234-1

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U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

APPLICATION FOR
APPROVAL OF LABELS,
MARKING OR DEVICE

1. AGENT NAME, ADDRESS,
TELEPHONE NO. (If using an Agent,
complete this block, otherwise leave
blank.)

3. FOR USDA USE ONLY

2. FOR USDA USE ONLY

4. ESTABLISHMENT NO. / FOREIGN
COUNTRY (If applicable)

FSIS has determined that information provided
in items 8, 9, and 10 is exempt from
mandatory disclosure under the Freedom of
Information Act 5 U.S.C. 552(b)(4).
APPLICANT: See Page 2 for instructions.
5a. NAME OF PRODUCT

5b. HACCP PROCESS CATEGORY

6a. TYPE OF APPROVAL REQUESTED
SKETCH

TEMPORARY

6b. WAS THE
LABEL
PREVIOUSLY
APPROVED?

YES
NO

EXTENSION OF TEMPORARY

7a. AREA OF PRINCIPAL DISPLAY PANEL (Square inches):
Date of approval:
Prior approval number:
7b. TOTAL AVAILABLE LABELING SPACE FOR ENTIRE PACKAGE (Square inches):

Number of labels on hand:
Number of days requested:

If Temporary or Extension is checked, use continuation sheet

PCT

8. PRODUCT FORMULA

WEIGHT

(No Fractions)

9. PROCESSING PROCEDURES
(Approval of the sketch does not convey approval of the processing procedures)

TOTAL (Percent must total 100%)
10. NAME AND ADDRESS OF FIRM (Below and between dots)

11. SIGNATURE OF APPLICANT OR AGENT

DATE

12. CONDITIONS APPLYING TO USE OF LABELS OR DEVICE (FOR USDA USE ONLY)

FSIS FORM 7234-1 (10/03/2002)

REPLACES FSIS FORM 7234-1 (11/87), WHICH IS OBSOLETE.

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Designed in FormFlow software.

INSTRUCTIONS FOR PREPARATION OF FSIS FORM 7234-1
Note: The following instructions should be typed unless otherwise noted.
A.

PREPARATION OF APPLICATION
Submit two copies for each label application. One additional copy is needed
for Foreign, Child Nutrition, Animal Production, or Organic Claims.

B.

SUBMISSION OF LABELS
Sketches: Self Explanatory. (See 9 CFR 317.4 & 381.132)
Temporaries and Request for Extension. Actual label or color litho take off to
be used. Quantity to Submit: Same as application (See above).

C.

FOREIGN LANGUAGE
Labels printed in foreign languages must be accompanied by English language
translation.

D.

ASSEMBLY OF APPLICATION
Staple, with 1 staple only, page 1, page 2, etc., one copy each. Staple all copies of label
to the back of application forms. If only page 1 is used, staple all copies
together. Use as few staples as possible. (Do not use paper clips).

E.

7a.

Area of Principal Display Panel (PDP). The PDP is the entire side
of the package to which the label is affixed. See 9 CFR 317.2 (d)
and 381.116 (b).

7b.

Total available labeling space in square inches for entire package.

8.

Product Formula. List the ingredients by percent or weight in order
of their predominance. If product consists of several components,
e.g., a frozen dinner, list each component separately and indicate
the percentage or amount of each component in the product. If
additional space is needed, complete a separate sheet of paper.
If using the electronic version of this form, use the continuation sheet.
Be sure to include the product name and number of the block item.
Express all ingredients in the same units, i.e., do not list some in
pounds and others in ounces.
Check whether weight or percent is used. It is preferred
percentages be used, and the total must equal 100 percent. If
weights are used, show in pounds, kilograms or grams. (No
gallons, pints, cups, teaspoons, etc.) The total must equal the
weights of the individual units. (Example: Crust + Cheese +
Sauce + Meat = Total new weight of unit.)

MAIL COMPLETE APPLICATION TO:
USDA, FSIS, OPPDE, Labeling and Consumer Protection Staff
1400 Independence Avenue, SW
Room 614 - Annex Building
WASHINGTON, DC 20250-3700

The following instructions relate to numbered items on form.
1.

If using an Agent, provide the company name, address, and telephone number,
otherwise leave blank.

2 & 3.

Leave blank, for USDA use only.

4.

Establishment No./Foreign Country (if applicable) - Self Explanatory.

5a.

Name of Product. Use common or descriptive product name, i.e., "Frankfurter ,
Cereal Added" or "Meat Patties in Gravy. (Do not use trade brand names or
coined names, such as "Joe's Corn Dogs" or "Joe's Sloppy Joes.") If coined
names such as "Corn Dogs" are used, also show true product name, such as
"Batter wrapped Wiener."

5b.

Provide HACCP process category for the product. See 9 CFR 417.2(b) (1),
Example, Heat Treated - shelf stable, Not heat treated-shelf stable etc.

6a & b.

Type of Approval Requested. If temporary approval or extension, insert
number of days requested and number of labels on hand. If previous
approval, attach copy of application and label. Include specific reason(s)
why requesting a temporary or extension and include information required
in 9 CFR 317.4(f) (1) or 381.132(f) (1) on a separate sheet of paper.
If using the electronic version of this form, use the continuation sheet.
Be sure to include product name and block item.

DO NOT use fractions. Express as decimals carried to two places,
Example: 1-1/4 lbs., show as 1.25 lbs. Example: 3/4 lbs., show as
.75 lbs.
9.

Processing Procedures. Poultry Products provide complete
processing procedures as required in 9 CFR 381.134. Meat
Products provide complete processing procedures as required.
Note: Approval of the sketch does not convey approval of the
processing procedures. If additional space is needed, complete
a separate sheet of paper. If using the electronic version of this
form, use the continuation sheet. Be sure to include the product
name and number of the block item.

10.

Name and Address of Firm. Insert Firm's name and mailing
address. Use 2 letter symbol for State. Show postal zip code.

11.

Signature and Date of Applicant or Agent. To be signed and
dated by the applicant or agent representing the official
establishment or plant.

12.

Conditions Applying to Use of Label or Device. Leave blank, for
USDA use only. (Any condition, modification or remarks applied
to the application when approved are conditions governing use of
the approved devices.)

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CONTINUATION SHEET FOR APPLICATION FOR APPROVAL OF LABELS,
MARKING OR DEVICE (FSIS 7234-1)
PRODUCT NAME

This sheet is being used for additional information required in Block: