5200-6 Application/Approval for Voluntary Inspection

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

INSTRUCTIONS: Submit this application to the District Manager, U.S. Department of
Agriculture, Food Safety and Inspection Service. Submit two sets of plans and four sets
of specifications of the plant, when required, as indicated below. Complete all sections.
If a section is not applicable, enter "N/A". If additional space is needed, use reverse
side and number the item.

APPLICATION / APPROVAL FOR VOLUNTARY
REIMBURSABLE INSPECTION SERVICE
2. TYPE OF APPLICATION
NEW

1. DATE OF APPLICATION

3. EST. NO. ASSIGNED/RESERVED

CHANGE/OWNER

CHANGE/LOCATION

OTHER (Specify):
5. FORM OF ORGANIZATION

4. NAME OF APPLICANT

INDIVIDUAL

PARTNERSHIP

CORPORATION

COOP. ASSOC.

6. IF INCORPORATED, GIVE DATE
OF INCORPORATION & STATE

OTHER (Specify):
7. APPLICANT'S MAILING ADDRESS: Street Address (up to 30 characters)

CITY (up to 16 characters)

STATE
(2)

ZIPCODE (up to 11 numbers)

8. TELEPHONE NUMBER (include
area code)

9. LOCATION OF PLANT IF DIFFERENT THAN ITEM 4: STREET ADDRESS
(up to 30 characters)

CITY (up to 16 characters)

STATE
(2)

ZIPCODE (up to 11 numbers)

10. TELEPHONE NUMBER (include
area code)

SERVICE REQUESTED
11.

ID SERVICE: Meat

COMPLETED BY USDA:
District Manager

REMARKS

ID SERVICE: Poultry

APPROVED

DISAPPROVED

12.

CERTIFICATION:
Trichnae

CERTIFICATION:
Cysticercus

CERTIFICATION:
Export

APPROVED

DISAPPROVED

13.

OFF-PREMISE
FREEZING: Meat

OFF-PREMISE
FREEZING: Poultry

OFF-PREMISE
FREEZING: Egg
Products

APPROVED

DISAPPROVED

APPROVED

DISAPPROVED

APPROVED

DISAPPROVED

17.

ANIMAL FOODS INSPECTION
(Certified products for Dogs, Cats, and other Carnivora)

APPROVED

DISAPPROVED

18.

TECHNICAL ANIMAL FATS
9 CFR 351

APPROVED

DISAPPROVED

14.
15.

16.

FOOD INSPECTION: (requires plans & specs)
VOLUNTARY MEAT & POULTRY
SLAUGHTER / PROCESSING
(Specify):

P = PROCESSING

S = SLAUGHTER

VOLUNTARY EGG PRODUCTS INSPECTION/PROCESSING
(Specify):

S-Antelope

S-Deer

S-Bison
S-Buffalo

S-Poultry

S-Catalo

S-Reindeer

S-Rabbit

P-Antelope
P-Bison
P-Buffalo
P-Catalo

P-Egg Products
P-Deer
P-Poulty
P-Rabbit
P-Reindeer

AGREEMENT AND CERTIFICATION: If inspection service is granted under this application, I (we) expressly agree to conform strictly to the provisions of the Agricultural Marketing Act of 1946
(7 U.S.C. 1621 et seq.) and the respective regulations thereunder. I certify that all statements made herein are true to the best of my knowledge and belief.
19. TYPE NAME OF PERSON SIGNING APPLICATION

20. SIGNATURE OF OWNER, PARTNER OR AUTHORIZED OFFICER
(making this application)

23. DATE RECEIVED

25. EST NO.

24. DATE FACILITY REVIEWED

FSIS FORM 5200-6 (2/15/2011)

21. TITLE

COMPLETED BY USDA

26. SIGNATURE OF DISTRICT MANAGER

REPLACES FSIS FORM 5200-6 (03/05/2002), WHICH MAY BE USED UNTIL EXHAUSTED.

22. DATE

27. DATE