Form 3537a R19

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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