Form 5020-1 (revised) 5020-1 (revised) (Revised) Registration of Meat and Poultry Handlers

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displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0128. The time required to complete this information collection
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U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE
OFFICE OF PROGRAM EVALUATION, ENFORCEMENT AND REVIEW

REGISTRATION OF
MEAT AND POULTRY HANDLERS

DISTRIBUTION: RETAIN ONE COPY FOR YOUR FILES, AND RETURN
ONE COPY OF THIS REPORT TO:

USDA, FSIS, OPEER, EED
1400 Independence Avenue, SW
Stop Code 3753, PP3, Cubicle 8-243A
Washington, D.C. 20250-3700
[email protected]

NOTICE TO MEAT AND POULTRY HANDLERS
Unless you operate under Federal Inspection, you are required by law to register with the U.S. Department of Agriculture if you deal in meat or poultry
products in or for commerce. (The term "commerce" means commerce between any State, any territory, or the District of Columbia, and any place
outside thereof; or within any territory not organized with a legislative body, or the District of Columbia, or within a State or Territory that has been
designated for 21 U.S.C. 643 and/or 21 U.S.C. 460 because such State or Territory does not operate a program of its own.)
INSTRUCTIONS: Complete items 1 through 10 and send both copies to the address in the upper right corner. USDA will return one copy of the
completed registration to the registrant in item 2.
1. Check the "original" box to indicate first time registration or check the "update" box for any changes to original form and highlight the changed information.
(When submitting an update, please specify the registration number.)
ORIGINAL

UPDATE

REGISTRATION NO.

2. NAME AND MAILING ADDRESS OF REGISTRANT (Include Zip Code)

PHONE:

3. FORM OF ORGANIZATION (Check or specify)
INDIVIDUALLY OWNED

PARTNERSHIP

INCORPORATED

COOPERATIVE
ASSOCIATION

LIMITED LIABILITY
CORPORATION

OTHER (Specify)

E-MAIL:

4. NATURE OF BUSINESS (Check one)
MEAT OR MEAT
PRODUCTS

POULTRY OR POULTRY
PRODUCTS

BOTH MEAT AND
POULTRY PRODUCTS

OTHER:

5. CHECK EACH TYPE OF BUSINESS YOU ARE ENGAGED IN
DOMESTIC BROKER

IMPORT BROKER

RENDERER

PUBLIC WAREHOUSEMAN

WHOLESALER

OTHER:

ANIMAL FOOD
MANUFACTURER

Buying, selling, transporting, or importing any dead, dying, disabled, or diseased cattle, sheep, swine, goats, horses, mules, equines,
poultry, or parts of the carcasses of any such animals or poultry that died otherwise than by slaughter. (4D Operator)
6. Address(es) of subsidiaries, branches, or divisions of your organization which engage in business of the type identified in Item 4.
Include trade or other names if different from your organization's. (If none, state none)

PHONE:

E-MAIL:

HOURS OF OPERATION

CHANGES: If you make any changes in the names, including trade names, or addresses of the place or places where you do business, report
such changes within 15 days to address in upper right corner.
7. TYPED OR PRINTED NAME

8. TITLE

CERTIFICATION BY FIRM OFFICIAL
9. SIGNATURE

10. DATE

NOTICE OF REGISTRATION BY USDA (COMPLETED BY USDA OFFICIAL)
a. REGISTRATION NO.

b. DATE OF REGISTRATION

FSIS FORM 5020-1 (11/28/2011)

REPLACES FSIS FORM 5020-1 (2/2/2007), WHICH MAY BE USED UNTIL EXHAUSTED.

c. TITLE OF USDA OFFICIAL

d. SIGNATURE OF USDA OFFICIAL

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INSTRUCTIONS FOR FSIS FORM 5020-1,
REGISTRATION OF MEAT AND POULTRY HANDLERS
OFFICIAL OF THE "MEAT AND POULTRY HANDLING" FIRM REQUIRED TO REGISTER: COMPLETE
BLOCKS 1-10 BEFORE SUBMITTING THE FORM TO FSIS.
Block 1.

Check the box that best describes the nature of the application (original for first time registrations,
or update to request changes (specify the registration number and highlight the changes)).

Block 2.

Enter the entire name and mailing address of the registering firm, include the phone number and
an E-mail address.

Block 3.

Check the box that describes the "Form of Organization" of the registering firm's organization.

Block 4.

Check the box that best describes the nature of the registrants business (meat or meat products
poultry or poultry products, both meat and poultry products, and other if applicable).

Block 5.

Check all the boxes that describe the "Type of Business" that the registrant is engaged in
(domestic broker, import broker, renderer, animal food manufacturer, warehouseman, wholesaler,
or other).

Block 6.

Enter the address or addresses of subsidiaries, branches, or divisions of the registrants
organization that engage in business of the type checked in block 4. Include any that do business
as names, trade names, or names that are different than the name entered in block 1. Include the
phone number, an E-mail address, and the hours of operation for each subsidiary, branch, or
division. Attach additional sheets if necessary.

Block 7.

Print or type the name of the registering official.

Block 8.

Print or type the title of the registering official.

Block 9.

Enter the signature of the registering official.

Block 10.

Enter the date when the registering official signs the form.

OPEER HEADQUARTERS PERSONNEL: FILL OUT BLOCKS A-D AFTER RECEIVING THE FORM
FROM THE REGISTRANT
Block a.

Choose a unique registration number (method to be determined).

Block b.

Enter the date the form is signed by a FSIS official.

Block c.

Enter the title of the FSIS official signing the form.

Block d.

Enter the signature of the FSIS official registering the firm.