5200-2 Application for Inspection

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0082. The time required to complete this information collection is
estimated to average 10 minutes 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.
Instructions: Submit this application to the District/Regional Office, Food
Safety and Inspection Service, U.S. Department of Agriculture for import
inspection requests. Complete all sections. If a section is not applicable,
enter "N/A" or "None." If additional space is needed for any item, attach
sheet and number the item.

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

APPLICATION FOR FEDERAL INSPECTION
(Meat, Poultry, Egg Product, Catfish and Import Inspection)
SECTION I.

ESTABLISHMENT INFORMATION

1. Date of Application

2. Type of Application
New

Change of Ownership

3. Type of Inspection Required (Check box)
Meat

Poultry

Change of Location

Application Extension

4. Form of Organization (Check box)

Egg Product

Individual

Import

Cooperative Association

Partnership

Corporation

LLC
5. If Corporation, Name of State Where Incorporated

8. Name of Applicant and Mailing Address (include zip
code)

7. Date Incorporated

6. Address of Corporate Headquarters

9. Federal Employer ID#

11. Area Code and
Telephone Number

10. Dun & Bradstreet #

12. Firm's Code (Import
Only)

14. Mailing Address if Different from Item 8 (include zip code) 15. Area Code and
Telephone Number

13. Actual Name of and Physical Address of Plant

16. Attach Limits or Establishment Premises to be under Federal Inspection (for egg plants attach blueprint)

17. Name and Establishment Number of other official
establishments located in the same facility

18. Doing Business As

19. Month and Year when establishment will be ready to operate under inspection

20. Comments

TYPE OF OPERATION

SECTION II.

MEAT AND POULTRY INSPECTION ACTIVITIES (Check all that apply.)
21 A. Animals to be slaughtered when inspecting is inaugerated (meat and poultry only)
a..

Beef

Sheep

Goats

Guineas

Squab

Ratites

Swine

b.

Raw - Ground (Non-Intact Products)

c.

Raw - Not Ground (Intact Products)

d.

Thermally Processed Commercially Sterile

e.

Not Heat Treated - Shelf Stable

f.

Heat Treated - Shelf Stable

g.

Fully Cooked - Not Shelf Stable

h.

Heat Treated but Not Fully Cooked - Not Shelf Stable

i.

Product with Secondary Inhibitors - Not Shelf Stable

FSIS Form 5200-2 (2/15/2011)

Equine

PREVIOUS EDITONS ARE OBSOLETE

Chicken

Turkeys

Goose

Ducks

FSIS Form 5200-2 (2/15/2011) Page 2

EGG PRODUCTS INSPECTION
21 B. Check the type of product intended for inspection at the establishment (Check all that apply)
a.

Shell Egg Breaking

b.

Thermally Processed (Pasteurized heat treated)
Cans/Pails

Jars

Flexible Pouches

Cartons

Totes

Bag-n-Box

c.

Not Heat Treated - Unpasteurized egg product only

d.

Heat Treated - Shelf Stable (Dried egg product, 50% Sugar Yolk)

e.

Heat Treated But Not Fully Cooked - not shelf stable (liquid and frozen egg products)

Tankers

Other

IMPORT INSPECTION
21 C. Species (Check all that apply)
Meat
22.
a.

Poultry

Check the type of product intended for inspection at the establishment (Check all that apply)
Raw - Non-Intact
Ground

b.

Other Non-Intact

Raw - Intact
Carcasses:

Other:

Veal

Beef
Mutton

c.

Catfish

Egg Products

Equine

Cuts

Veal
Hide On

Goats

Poultry

Ratites
Other Intact

Boneless Manufacturing Meats

Thermally Processed Commercially Sterile
Cans

Flexible Pouches

d.

Not Heat Treated - Shelf Stable

e.

Heat Treated - Shelf Stable

f.

Fully Cooked - Not Shelf Stable

Trays

Jars

Frozen from an APHIS restricted country (9CFR 94.4(b))
g.

Heat Treated But Not Fully Cooked - Not Shelf Stable

h.

Product with Secondary Inhibitors - Not Shelf Stable

i.

Shell Eggs/Egg Products
Shell Eggs

23.

Sheep

Pork

Liquid

Frozen

Frozen

Perishable

Dried

Mode of Transportation - Import Inspection Only (Check all that apply)
Tankers

Rail Cars

Trucks

Ocean Vessel

Airline

Other (Specify)

Lamb

FSIS Form 5200-2 (2/15/2011) Page 3

SECTION III

OWNERSHIP AND MANAGEMENT INFORMATION

24. List all persons responsibly connected with the applicant. Include all owners, partners, officers, directors, holders or owners of 10 per centum or
more of voting stock and employees in a managerial or executive capacity in the business. Notify the Division Director or import Inspection Division
Director of any changes in the listing given.
Name and Title
Present Home Address
HOLDER OF 10% OR
(Title - Indicate if partner or manager)
(Street and Number, City, State, Zip Code)
MORE VOTING STOCK
(If Corp.)
YES

NO

25. Enter the name of each person listed under Item 24 who has been convicted in any Federal or State court of any felony. Enter the name of each
person listed under item 24 who has been convicted in any Federal or State court of more than one violation of any law, other than a felony, based
upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or upon fraud in connection with transactions in
food. Include the nature of the crime, the date of conviction and the court in which convicted. If none write "None."

26. List each conviction against the applicant (person, firm or corporation) in any Federal or State court of any felony, List each conviction against the
applicant (person, firm or corporation) in any Federal or State court of more than one violation of any law, other than a felony, based upon the
acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or upon fraud in connection with transactions in food.
Include the nature of the crime, the date of conviction and the court in which convicted. If none write "None."

27. Sanitation Standard Operating Procedures have been developed for the establishment in accordance with
(Check one)
YES

§ 416.12 of the regulations.

NO

28. Applicant has been provided with a copy of this Privacy Act Notice. (Check one)
YES

29. Typed name of person signing application

NO

30. Signature

31. Title

TO BE COMPLETED BY USDA, FSIS
32. Is this establishment presently under state inspection? (OFO only)
33. Is this establishment to be under Talmadge-Aiken Act? (OFO only)
34. Official inspection number reserved

YES

NO

YES

NO

35. Signature of DM or IID Director

36. Date