Form 3537a DHHS/FDA CANCELLATION OF FOOD FACILITY REGISTRATION FORM

Registration of Food Facilities Under the Public Health Security and Bioterrorism Preparedness and Response Act of 2002

0502 Form 3537a

21 CFR 1.235 Reporting; Requires the Registration For a Previously Registered Facility to Be Cancelled When The Facility Ceases to Operate ... .

OMB: 0910-0502

Document [doc]
Download: doc | pdf

Form Approval: OMB No. 0910-xxxx

Expiration Date:

See OMB Statement at end of form

FDA USE ONLY


USE BLUE OR BLACK INK ONLY

DHHS/FDA CANCELLATION OF FOOD FACILITY REGISTRATION FORM

FACILITY REGISTRATION NUMBER:

PIN:

O DOMESTIC REGISTRATION

O FOREIGN REGISTRATION

FACILITY NAME / ADDRESS INFORMATION

FACILITY NAME:

FACILITY STREET ADDRESS, Line 1:

FACILITY STREET ADDRESS, Line 2:

CITY:

STATE:

ZIP CODE (POSTAL CODE):

PROVINCE/TERRITORY:

COUNTRY:

CERTIFICATION STATEMENT

The owner, operator, or agent in charge of the facility, or an individual authorized by the owner, operator, or agent in charge of the facility, must submit this form. By submitting this form to FDA, or by authorizing an individual to submit this form to FDA, the owner, operator, or agent in charge of the facility certifies that the above information is true and accurate. An individual (other than the owner, operator, or agent in charge of the facility) who submits the form to the FDA also certifies that the above information submitted is true and accurate and that he/she is authorized to submit the cancellation on the facility's behalf. An individual authorized by the owner, operator, or agent in charge must below identify by name the individual who authorized submission of the cancellation. Under 18 U.S.C. 1001, anyone who makes a materially false, fictitious, or fraudulent statement to the U.S. Government is subject to criminal penalties.

SIGNATURE OF SUBMITTER

PRINT NAME OF THE SUBMITTER

CHECK ONE BOX: O A. OWNER, OPERATOR OR AGENT IN CHARGE (STOP HERE, FORM IS COMPLETED)

O B. INDIVIDUAL AUTHORIZED TO SUBMIT THE CANCELLATION (FILL IN BELOW)

IF YOU CHECKED BOX B ABOVE, INDICATE WHO AUTHORIZED YOU TO SUBMIT THE CANCELLATIONFILL IN THE FOLLOWING INFORMATION:

O OWNER, OPERATOR, OR AGENT IN CHARGE (STOP HERE, FORM IS COMPLETED)

O ____________________________________________________________ NAME OF INDIVIDUAL WHO AUTHORIZED

CANCELLATION ON BEHALF OF OWNER, OPERATOR, OR AGENT IN CHARGE, IF DIFFERENT FROM FACILITY INFORMATION ABOVE (FILL IN BELOW)

ADDRESS INFORMATION FOR THE AUTHORIZING INDIVIDUAL, IF DIFFERENT FROM FACILITY INFORMATION ABOVE:

FACILITY STREET AUTHORIZING INDIVIDUAL ADDRESS, Line 1:

AUTHORIZING INDIVIDUAL FACILITY STREET ADDRESS, Line 2:

CITY:

STATE:

ZIP CODE (POSTAL CODE):

PROVINCE/TERRITORY:

COUNTRY:

PHONE NUMBER (Include Area/Country Code):

FDA USE ONLY

DATE CANCELLATION FORM RECEIVED

DATE CONFIRMATION SENT TO FACILITY

MAIL COMPLETED FORM TO U.S. FOOD AND DRUG ADMINISTRATION, HFS-681, 5600 FISHERS LANE, ROCKVILLE, MD 20857, OR FAX IT TO (301) 210-0247.

Public reporting burden for this collection of information is estimated to average 1 hour 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:

Department of Health and Human Services An agency may not conduct or sponsor, and a

Food and Drug Administration person is not required to respond to a collection of

CFSAN (HFS-024) information, unless it displays a currently valid

5100 Paint Branch Parkway OMB control number.

College Park, MD 20740

Form 3537a (1/03)

File Typeapplication/msword
File TitleForm 3537a R19
SubjectFFRM Cancellation Form
AuthorPeggy Robbins
Last Modified ByPeggy Robbins
File Modified2003-09-29
File Created2003-09-29

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