5200-6 Application_Approval for Voluntary Reimbursable Inspecti

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OMB Control Number 0583-0153
Expiration Date:
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U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

INSTRUCTIONS: Submit this application to the District Manager, U.S. Department of
Agriculture, Food Safety and Inspection Service. Submit two sets of plans and four sets
of specifications of the plant, when required, as indicated below. Complete all sections.
If a section is not applicable, enter "N/A". If additional space is needed, use reverse
side and number the item.

APPLICATION / APPROVAL FOR VOLUNTARY
REIMBURSABLE INSPECTION SERVICE
2. TYPE OF APPLICATION
NEW

1. DATE OF APPLICATION

3. EST. NO. ASSIGNED/RESERVED

CHANGE/OWNER

CHANGE/LOCATION

OTHER (Specify):
5. FORM OF ORGANIZATION

4. NAME OF APPLICANT

INDIVIDUAL

CORPORATION

PARTNERSHIP

COOP. ASSOC.

6. IF INCORPORATED, GIVE DATE
OF INCORPORATION & STATE

OTHER (Specify):
7. APPLICANT'S MAILING ADDRESS: Street Address (up to 30 characters)

CITY (up to 16 characters)

STATE
(2)

ZIPCODE (up to 11 numbers)

8. TELEPHONE NUMBER (include
area code)

9. LOCATION OF PLANT IF DIFFERENT THAN ITEM 4: STREET ADDRESS
(up to 30 characters)

CITY (up to 16 characters)

STATE
(2)

ZIPCODE (up to 11 numbers)

10. TELEPHONE NUMBER (include
area code)

SERVICE REQUESTED
11.

ID SERVICE: Meat

COMPLETED BY USDA:

REMARKS

District Manager

ID SERVICE: Poultry

APPROVED

DISAPPROVED

ID SERVICE: Siluriformes
12.

CERTIFICATION:
Trichnae

CERTIFICATION:
Cysticercus

CERTIFICATION:
Export

APPROVED

DISAPPROVED

13.

OFF-PREMISE
FREEZING: Meat

OFF-PREMISE
FREEZING: Poultry

OFF-PREMISE
FREEZING: Egg
Products

APPROVED

DISAPPROVED

OFF-PREMISE
FREEZING: Siluriformes
14.

15.

16.

FOOD INSPECTION: (requires plans & specs)
S = SLAUGHTER
S-Antelope

VOLUNTARY MEAT & POULTRY
SLAUGHTER / PROCESSING
(Specify):
VOLUNTARY EGG PRODUCTS INSPECTION/PROCESSING
(Specify):

17.

18.

S-Elk

S-Bison

S-Poultry

S-Buffalo
S-Catalo
S-Deer

P = PROCESSING
P-Antelope

P-Elk

P-Bison

P-Poulty

S-Rabbit

P-Buffalo

P-Rabbit

S-Reindeer

P-Catalo

P-Reindeer

S-Yak

P-Egg Products

P-Yak

APPROVED

DISAPPROVED

APPROVED

DISAPPROVED

APPROVED

DISAPPROVED

APPROVED

DISAPPROVED

P-Deer

ANIMAL FOOD INSPECTION

(Certified products for Dogs, Cats, and other Carnivora)
(Specify):
TECHNICAL ANIMAL FATS

APPROVED

9 CFR 351

(Specify):

DISAPPROVED

AGREEMENT AND CERTIFICATION: If inspection service is granted under this application, I (we) expressly agree to conform strictly to the provisions of the Agricultural Marketing Act of 1946
(7 U.S.C. 1621 et seq.) and the respective regulations thereunder. I certify that all statements made herein are true to the best of my knowledge and belief.
19. TYPE NAME OF PERSON SIGNING APPLICATION

20. SIGNATURE OF OWNER, PARTNER OR AUTHORIZED OFFICER
(making this application)

21. TITLE

22. DATE

COMPLETED BY USDA
23. DATE RECEIVED

24. DATE FACILITY REVIEWED

FSIS FORM 5200-6 (08/04/2021)

25. EST NO.

26. SIGNATURE OF DISTRICT MANAGER

REPLACES FSIS FORM 5200-6 (02/17/2011), WHICH MAY BE USED UNTIL EXHAUSTED.

27. DATE