5200-7 Authorization Certificate

OMB Control Number 0583-0092
Expiration Date:

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 0583-0092. The time required to complete this information collection is
estimated to average 4 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.
U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE
FIELD OPERATIONS

AUTHORIZATION CERTIFICATE

DISTRIBUTION:
Original = to Manufacturer
Copy 1 = to Manufacturer
Copy 2 = Retained by FSIS Office
Copy 3 = Retained by Official Establishment

CERTIFICATE NUMBER

A

This certificate, when signed by an authorized representative of the Administrator, authorizes the making of brands or other devices bearing official
inspection legends.
SECTION 1 - ITEMS 1-12 COMPLETED BY ESTABLISHMENT. ITEMS 13-20 COMPLETED BY MANUFACTURER
1. ESTABLISHMENT NO.

2. ESTABLISHMENT NAME

3. STREET ADDRESS
4. CITY

5. STATE

7. SIGNATURE OF ESTABLISHMENT OFFICIAL

6. ZIP CODE
8. DATE

9. NAME AND ADDRESS OF FIRM BRANDS OR DEVICES BEING ORDERED FROM

10. NUMBER OF
BRANDS /
DEVICES

11. SIZE (If applicable)

13. SERIAL NUMBER(S) (To be completed by manufacturers)

12. TYPE (Hot, cold)

14. NAME OF MANUFACTURER
15. STREET ADDRESS
16. CITY

17. STATE

19. SIGNATURE OF BRAND MANUFACTURER



18. ZIP CODE
20. DATE

NOTE TO MANUFACTURER: Send Brand(s)/Device(s) and Copy 1 of this certificate to the address below.
SECTION II - AUTHORIZATION - TO BE COMPLETED BY FSIS, FO, PROGRAM EMPLOYEE

1. NAME OF USDA, FSIS, FO, EMPLOYEE (To receive brands / devices from manufacturer)
2. STREET ADDRESS
3. CITY

4. STATE

6. NAME OF FSIS, FO, EMPLOYEE MAKING AUTHORIZATION

7. TITLE

8. SIGNATURE OF FSIS, FO, EMPLOYEE MAKING AUTHORIZATION

FSIS FORM 5200-7 (2/14/2012)

5. ZIP CODE

20. DATE

REPLACES FSIS FORM 5200-7 (12/8/2010), WHICH MAY BE USED UNTIL EXHAUSTED.