Form 3733 DHHS/FDA Shell Egg Producer Registration

Form Approval: OMB No. 0910-0660; Expiration date: August 31, 2016; See Reporting Burden Statement on page 3.

FDA USE ONLY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

DHHS/FDA SHELL EGG PRODUCER REGISTRATION
(If entering by hand, use black or dark blue ink only.)

Date (mm/dd/yyyy)

Section 1 - TYPE OF REGISTRATION
1a.

DOMESTIC REGISTRATION

FOREIGN REGISTRATION

1b.

INITIAL REGISTRATION

UPDATE OF REGISTRATION INFORMATION

NOTIFICATION OF CEASING OPERATIONS AS OF DATE (mm/dd/yyyy) :
Facility Registration Number

1c.

If update or ceasing operations notification, provide
the Facility Registration Number.

1d.

If update, check all that apply and further identify changes in the applicable sections.
Facility Name Change

Seasonal Facility Dates of Operation Change

Facility Address Change (See instructions)

Size of Operation Change

Preferred Mailing Address Change

Owner or Operator Change

1e. ARE YOU THE NEW OWNER OF A PREVIOUSLY REGISTERED FACILITY?
If "Yes," provide the following information, if known.
Previous owner's name

Yes

No

Previous owner's registration number

Section 2 - 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)

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

FORM FDA 3733 (8/14)

E-Mail Address (Optional)

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PSC Publishing Services (301) 443-6740

EF

Section 3 - (OPTIONAL) PREFERRED MAILING ADDRESS INFORMATION - Complete this section only if different
from Section 2, Facility Name/Address Information.
Name
Street Address, Line 1
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)

FAX Number (Optional; Include Area/Country Code)

E-Mail Address (Optional)

Section 4 - (OPTIONAL) SEASONAL FACILITY DATES OF OPERATION - Give the approximate dates that your
facility is open for business, if its operations are on a seasonal basis.
Dates of Operation

Section 5 - SIZE OF OPERATION
Average or usual number of layers in each poultry house

Number of poultry houses on the farm

Section 6 - OWNER OR OPERATOR INFORMATION
Name of Entity or Individual Who Is the Owner or Operator

Provide the following information, if different from all other sections on the form. If the information is the same as another section of the form,
check which section.
SECTION 2

SECTION 3

Street Address, Line 1
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)

FAX Number (Optional; Include Area/Country Code)

FORM FDA 3733 (8/14)

E-Mail Address (Optional)

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Section 7 - CERTIFICATION STATEMENT
The owner or operator of the facility, or an individual authorized by the owner or operator 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 or
operator of the facility certifies that the above information is true and accurate. An individual (other than the owner or
operator 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 registration on the facility's behalf. An individual authorized by the
owner or operator must below identify by name the individual who authorized submission of the registration. 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

Printed Name of Submitter
Check One Box

A. OWNER OR OPERATOR (STOP HERE; FORM IS COMPLETED)
B. INDIVIDUAL AUTHORIZED TO SUBMIT THE REGISTRATION (FILL IN BELOW)
If you checked Box B above, indicate who authorized you to submit the registration.
OWNER OR OPERATOR (STOP HERE; FORM IS COMPLETED)
– NAME OF INDIVIDUAL WHO AUTHORIZED
REGISTRATION ON BEHALF OF OWNER OR OPERATOR (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)

FAX Number (Optional; Include Area/Country Code)

E-Mail Address (Optional)

MAIL COMPLETED FORM FDA 3733 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

Date Notification Sent to Facility

Facility Status (Check one)
Active

Inactive

The burden time for this collection of information is estimated to average 2.3 hours per response, including the time to review
instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information.
Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing
this burden, to:
Department of Health and Human Services
Do not send your completed form to the PRA Staff email address to the left.
Food and Drug Administration
“An agency may not conduct or sponsor, and a person is not
Office of Chief Information Officer
required to respond to, a collection of information unless it
Paperwork Reduction Act (PRA) Staff
displays a currently valid OMB number.”
[email protected]

FORM FDA 3733 (8/14)

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Instructions for Form FDA 3733
Shell Egg Producer Registration
NOTE: Form FDA 3733 is used to register a farm, to provide an update to an existing registration, or to notify FDA
that you are ceasing operations. The owner or operator of the facility, or an individual authorized by the owner or
operator of the facility, such as an agent in charge, must fill out, sign, and submit this form.
An individual (other than the owner or operator) who submits this form to FDA must, in section 7 of the form
(certification statement), identify by name the individual who authorized submission of the registration. Form FDA
3733 must be signed and printed or typed with black or dark blue ink. If there is no information available for a
specific block in a mandatory section, enter the words “Not Available,” “N/A,” or “None” in that block unless specified
otherwise in these instructions. Do not make any entries or marks in the parts of the form designated “FDA USE
ONLY.” Some sections of the form contain a check box for making a selection. Check the box when making a
selection. All sections on this form are mandatory unless described otherwise. Forms that are incomplete or illegible
will not be processed and may considerably delay a requested action (such as issuance of a Shell Egg Producer
Registration Number).

Date
Enter the date in the format MM/DD/YYYY. Example: 07/09/2010

Section 1 – TYPE OF REGISTRATION
Subsection 1a. DOMESTIC OR FOREIGN REGISTRATION
Check the box for only one of the two choices. Domestic means that the farm is located in any State or Territory of
the U.S., in the District of Columbia, or in the Commonwealth of Puerto Rico. Foreign means all others.
Subsection 1b. INITIAL REGISTRATION
Check the box for Initial Registration only if this is the first time you have registered this farm with FDA under FDA’s
final rule, “Prevention of Salmonella Enteritidis in Shell Eggs During Production, Storage, and Transportation.”
Subsection 1b. UPDATE OF REGISTRATION INFORMATION
If you are updating information for an existing Shell Egg Producer Registration, please check this box and provide
the current Registration Number in subsection 1c. A form submitting an update will not be processed without the
appropriate Registration Number.
Subsection 1b. NOTIFICATION OF CEASING OPERATIONS
If you are ceasing or have ceased operations, check this box and enter the date that you will be ceasing (or have
ceased) operations.
Subsection 1c. UPDATE OR CEASING OPERATIONS NOTIFICATION
If this is an update or ceasing operations notification, provide the Shell Egg Producer Registration Number in the
blank.
Subsection 1d. UPDATE INFORMATION
Check the box for each update that applies and further identify changes in the applicable section(s). If this is a new
registration, leave this section blank.
Subsection 1e. NEW OWNER INFORMATION
If you are a new owner of a previously registered facility, you must re-register. Please provide the previous owner’s
name and registration number, if known.

Section 2 – FACILITY NAME/ADDRESS INFORMATION
Provide the requested information in the blocks provided. If the facility name and address are already listed with the
FDA for some other purpose, be sure to use the exact same facility name and address for Section 2.
FORM FDA 3733 (8/14)

Instructions Page 1

Section 3 – PREFERRED MAILING ADDRESS INFORMATION (OPTIONAL)
If you prefer to be contacted at an address other than that of the facility, please print or type the requested
information in the blocks provided in this section of the form.

Section 4 – SEASONAL FACILITY DATES OF OPERATION (OPTIONAL)
If your farm operates only during parts of the year, enter the date ranges when the facility operates. Example: “Open
June 1st through August 31st and October 1st through December 20th.”

Section 5 – SIZE OF OPERATION
Fill in the average or usual number of layers in each poultry house on the farm and the total number of poultry
houses on the farm.

Section 6 – OWNER OR OPERATOR INFORMATION
If the contact information for the owner OR operator is the same as that in another section of the form, check the
box corresponding to that section; otherwise, enter the information as requested. The fax number and e-mail
address for the owner or operator are optional.

Section 7 – CERTIFICATION STATEMENT
Either the owner or operator of the facility, or an individual authorized by the owner or operator of the facility, such
as an agent in charge, must submit this form. By submitting the form to FDA, or by authorizing an individual to
submit the form to FDA, the owner or operator of the facility is certifying that the information contained in the form is
true and accurate. If an individual authorized by the owner or operator of the facility submits the form to FDA, that
individual also certifies that the information contained in the form is true and accurate and that he/she is authorized
to submit the registration on the facility’s behalf. An individual authorized by the owner or operator of the facility
must identify in this section the name and contact information for the individual who authorized submission of the
registration. Anyone who makes a materially false, fictitious, or fraudulent statement to the U.S. Government is
subject to criminal penalties under 18 U.S.C. 1001.

Signature of Submitter
The submitter is required to sign this form in black or dark blue ink.
Printed Name of Submitter
Print or type the name of the person submitting the registration in this space.
Check One Box
If the submitter is the owner or operator, check box A, “OWNER OR OPERATOR.” If the submitter is an
individual authorized by the owner or operator (such as an administrative employee), check box B, “INDIVIDUAL
AUTHORIZED TO SUBMIT THE REGISTRATION.”
If you checked box B, check either the box, “ Owner or Operator ,” if the owner or operator authorized you to
submit the registration), or the box, “_______ – Name of individual who authorized registration on behalf of the
owner or operator ,” if someone other than the owner or operator authorized you to submit the registration. If you
checked, “Owner or Operator,” you are finished with the form. If you checked, “________ – Name of individual who
authorized registration on behalf of the owner or operator,” complete the name and address information for the
individual who authorized you to submit the registration on behalf of the owner or operator. The fax number and
e-mail address for that individual are optional.

MAILING PROCEDURES
Do not mail these instructions back to the FDA with your form. Keep them with your records.
Mail Completed Form FDA 3733 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.
FORM FDA 3733 (8/14)

Instructions Page 2