Form FSIS 10,110-2 FSIS 10,110-2 Rev. Application for Accreditation

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US Department of Agriculture
Food Safety Inspection Service
Accredited Laboratory Program
950 College Station Road
Athens, GA 30605

Application for FSIS Accredited Laboratory Program

LABORATORY NAME:

STREET ADDRESS (PO Box alone not acceptable):

CITY:

STATE:

NAME OF PRIMARY CONTACT:

TITLE OF PRIMARY CONTACT:

PHONE NUMBER:

FAX NUMBER:

NAME OF OWNER/MANAGER:

ZIP CODE:

EMAIL ADDRESS:

TITLE OF OWNER/MANAGER:

Yes

1. ACCREDITATION REQUESTED:

No

A. FOOD CHEMISTRY (Moisture, Protein, Fat, and Salt)
B. RESIDUE CHEMISTRY
Chlorinated Hydrocarbons (CHC)
Polychlorinated Biphenyls (PCB)
Arsenic (As)
Sulfonamides
Nitrosamines

2. IF YOUR LABORATORY IS CURRENTLY ACCREDITED BY THE FSIS ALP, PLEASE PROVIDE YOUR ALP LABORATORY NUMBER BELOW:
LABORATORY NUMBER:
3

HAS YOUR LABORATORY EVER BEEN PEVIOUSLY ACCREDITED BY THE ALP UNDER
THE PRESENT OR DIFFERENT NAME? (If no, proceed to section 5)

Yes

No

Yes

No

3a. If you answered yes in section 3, please provide the ALP laboratory number and the type of accredited analysis:

ALP #

ANALYSIS

4. WAS YOUR FSIS ALP ACCREDITATION EVER PLACED ON PROBATION AND/OR REVOKED?

4a. If you answered yes in section 4, please provide the most recent probation/revocation date:
FSIS FORM 10,110-2 (01/27/2014)

REPLACED FSIS FORM 10,110-2 (8/95) WHICH IS OBSOLETE

DATE
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Application for FSIS Accredited Laboratory Program
5. IS YOUR LABORATORY CURRENTLY ACCREDITED BY ANY OTHER STATE OR FEDERAL
PROGRAM?

Yes

No

5a. If you answered yes in section 5, please provide the name and description of the programs
a. NAME:

b. DESCRIPTION:

6. LABORATORY SUPERVISOR HAS A BACHELOR’S DEGREE OR HIGHER IN:
(Please enclose transcript or proof of degree. Proof is subject to verification with the degree granting institution)

Years
Experience

Chemistry

Food Science

Food Technology

Related Field (specify):
7. HAS THE LABORATORY OR ANY INDIVIDUAL OR ENTITY RESPONSIBLY CONNECTED WITH THE
LABORATORY BEEN INDICTED OR HAVE CHARGES BEEN BROUGHT AGAINST THE LABORATORY OR
RESPONSIBLY CONNECTED INIDIVIDUAL OR ENTITY, IN A FEDERAL OR STATE COURT, CONCERNING ANY
OF THE FOLLOWING VIOLATIONS OF LAW?

Yes

No

A. Any felony
B. Any misdemeanor based upon acquiring, handling, or distributing of unwholesome,
misbranded, or deceptively packaged food or upon fraud in connection with transactions in food.
C. Any misdemeanor based on false statement to any government agency.
D. Any misdemeanor based upon the offering, giving, or receiving of bribe or unlawful gratuity.

I certify that, to the best of my knowledge and belief, all information contained herein is true and understand that any willful falsification of this certification is a felony and may result in a
fine of $250,000 or more for an individual or $500,000 or more for a corporation and imprisonment for not more than 5 years or both (18 USC 1001, 3571, and 3623). I have read the
rules and requirements contained in 9 CFR Parts 391 and 439 and agree to abide by these rules and other requirements of the FSIS Accredited Laboratory Program.
SIGNATURE:

FSIS FORM 10,110-2 (01/27/2014)

DATE:

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TO BE COMPLETED BY ACCREDITED LABORATORY PROGRAM OFFICIALS
Fees paid?

On site review required?

Yes

No

Yes

No
Pass

ACCREDITATION CHECK SAMPLES

Fail

First Analysis:
Second Analysis:

OTHER SUPPORTING DOCUMENTATION NEEDED FOR REVIEW:

Approved

Denied (attach reason for denial)

LABORATORY NUMBER:
NAME OF REVIEWING OFFICIAL:

DATE:

SIGNATURE:

FSIS FORM 10,110-2 (01/27/2014)

REPLACED FSIS FORM 10,110-2 (8/95) WHICH IS OBSOLETE

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