Form FDA 3537a FDA 3537a Cancellation of Food Facility Registration

Form Approval: OMB No. 0910-0502; Expiration date: 8/31/2013; See OMB Statement below.

FDA USE ONLY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

DHHS/FDA CANCELLATION OF FOOD FACILITY REGISTRATION
(If entering by hand, use blue or black ink only.)

Facility Registration Number:

DOMESTIC REGISTRATION

PIN:

FOREIGN REGISTRATION

FACILITY NAME / ADDRESS INFORMATION
Facility Name
Facility Street Address, Line 1
Facility Street Address, Line 2
City

State (If applicable; if not,
skip to Province/Territory)

ZIP or Postal Code

Country

Province/Territory (If applicable)

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 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
Check One Box

Printed Name of Submitter

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

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

If you checked Box B above, indicate who authorized you to submit the cancellation.
OWNER, OPERATOR OR AGENT IN CHARGE (STOP HERE, FORM IS COMPLETED)
- NAME OF INDIVIDUAL WHO AUTHORIZED
CANCELLATION ON BEHALF OF OWNER, OPERATOR, OR AGENT IN CHARGE (FILL IN ADDRESS BELOW)
Address Information for the Authorizing Individual
Authorizing Individual Street Address, Line 1
Authorizing Individual Street Address, Line 2
City

State (If applicable; if not,
skip to Province/Territory)

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

MAIL COMPLETED FORM FDA 3537a TO U.S.
FOOD AND DRUG ADMINISTRATION, FOOD
FACILITY REGISTRATION, 5100 PAINT BRANCH
PARKWAY, HFS-681, COLLEGE PARK, MD 20993
OR FAX IT TO 301-436-2804

FDA USE ONLY
Date Registration Form Received

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 the address to the right.

Date Notification Sent to Facility

Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
1350 Piccard Drive, Room 400
Rockville, MD 20850

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number.

FORM FDA 3537a (8/11)

PSC Publishing Services (301) 443-6740

EF