Form 10110-2 Application for FSIS Accredited Laboratory Program

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US Department of Agriculture
Food Safety Inspection Service

Application for FSIS Accredited Laboratory Program

Office of Public Health Science
Accredited Laboratory Program
Athens, GA 30605

LABORATORY NAME:

STREET ADDRESS (PO Box alone not acceptable):

NAME OF PRIMARY CONTACT:

CITY:

TITLE OF PRIMARY CONTACT:

STATE:

PHONE NUMBER:

NAME OF OWNER/MANAGER:

ZIP CODE:

EMAIL ADDRESS:

TITLE OF OWNER/MANAGER:

1. ACCREDITATION REQUESTED:

Yes

No

A. FOOD CHEMISTRY (Moisture, Protein, Fat, and Salt)
B. RESIDUE CHEMISTRY
Chlorinated Pesticides
Polychlorinated Biphenyls (PCB)
Specify Accreditation(s):

Please contact the ALP at [email protected] for available accreditation(s).
C. MICROBIOLOGY
Specify Accreditation(s):

Please contact the ALP at [email protected] for available accreditation(s).
Laboratories are required to have the proper APHIS permits to participate in ALP Microbiology accreditations.
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 measurand:

ALP #
4.

WAS YOUR FSIS ALP ACCREDITATION EVER PLACED ON SUSPENSION AND/OR REVOKED?

MEASURAND

DATE

4a. If you answered yes in section 4, please provide the most recent suspension/revocation date:

5. IS YOUR LABORATORY CURRENTLY ACCREDITED BY ANY OTHER STATE OR FEDERAL
PROGRAM?

FSIS FORM 10,110-2 (08/25/2022)

Yes

No

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Application for FSIS Accredited Laboratory Program
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). Check All That Apply:

Years
Experience

Chemistry
Food Science
Food Technology
Biology
Microbiology
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:

Please submit the completed form to: [email protected]

FSIS FORM 10,110-2 (08/25/2022)

DATE:

.

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TO BE COMPLETED BY ACCREDITED LABORATORY PROGRAM OFFICIALS
Fees paid?

Yes

No

On site review required?

Yes

No

ACCREDITATION QUALIFICATION SAMPLES

Pass

Fail

First Analysis:
Second Analysis:
Third Analysis:
OTHER SUPPORTING DOCUMENTATION NEEDED FOR REVIEW:

Approved

Denied (attach reason for denial)

LABORATORY NUMBER:
NAME OF REVIEWING OFFICIAL:
SIGNATURE:

FSIS FORM 10,110-2 (08/25/2022)

DATE:

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