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

Form Approval: OMB No. 0910-0502; Expiration date: 8/31/2016; See OMB Statement below.
DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

FDA USE ONLY

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

□ DOMESTIC REGISTRATION

□ 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

Province/Territory (If applicable)

Country

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
Printed Name of Submitter

INFORMATION ABOUT INDIVIDUAL SUBMITTING THE CANCELLATION
Street Address, Line 1
Street Address, Line 2
City
ZIP or Postal Code

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

Province/Territory (If applicable)

E-Mail Address (If available )
Check One Box

□ 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)

E-Mail Address (Required unless FDA has granted a waiver under 21 CFR 1.245)
MAIL COMPLETED FORM FDA 3537a TO FDA USE ONLY
U.S. FOOD AND DRUG ADMINISTRATION, Date Registration Form Received
FOOD FACILITY REGISTRATION, 5001
CAMPUS DRIVE, HFS-681, COLLEGE
PARK, MD 20740
OR FAX IT TO 301-436-2804

Date Notification Sent to Facility

This section applies only to the requirements of the Paperwork Reduction Act of 1995: The public reporting burden
time for this collection of information is estimated to average 1 hour 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 the address to the right:

Department of Health and Human Services
Food and Drug Administration Office of Chief
Information Officer Paperwork Reduction Act
(PRA) Staff [email protected]

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 (11/14)

PSC Publishing Services (301) 443-6740

EF