9540-5 Notification of Intent

OMB Control Number 0583-0161
Expiration Date: 06/30/2025
This information collection is necessary to ensure that samples imported into the United States are not mixed with product that will be sold or distributed in commerce. (9 CFR 327.19, and
381.207, and 590.960). OMB Approved No. 0583-0161. OMB DISCLOSURE STATEMENT: Public reporting burden for this collection of information is estimated to average 20 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.
Send comments regarding this burden estimate or any other aspect of the collection of the information, including suggestions for reducing this burden to the Department of Agriculture,
Clearance Officer, OIRM, Room 404-W, Washington, D.C., 20250; and to the Office of Management and Budget, Paperwork Reduction Project, (OMB No. 0583-0094), Washington, D.C.,
20250. If the OMB clearance number does not appear on this form, you are not obligated to complete it.
United States Department of Agriculture
Food Safety and Inspection Service

NOTIFICATION OF INTENT
TO IMPORT MEAT, POULTRY, OR EGG PRODUCTS
"SAMPLES FOR LABORATORY EXAMINATION, RESEARCH,
EVALUATIVE TESTING OR TRADE SHOW EXHIBITION"

1. U.S. PORT OF ENTRY (port of entry)

3. FOREIGN EST. NO. (if applicable)

2. COUNTRY OF ORIGIN
(if applicable)

4. DATE OF NOTIFICATION

5. NAME AND ADDRESS OF IMPORTER

6. NAME, ADDRESS, PHONE NO. OF CUSTOMS BROKER OR
APPLICANT

7. NAME, ADDRESS AND PHONE NO. OF CONSIGNEE

8. ADDRESS, PHONE NUMBER TO WHERE THE SAMPLES WILL
BE SHIPPED (if different from consignee, number 7)

9. NAME OF PRODUCT AND SPECIES DERIVED FROM

10. NET WEIGHT (lbs.)

11. NUMBER OF CARTONS OR UNITS

12. TYPE/METHOD OF PACKAGING

13. INTENDED USE OF SAMPLES
LABORATORY
EXAMINATION

EVALUATIVE TESTING

RESEARCH

TRADE SHOW
EXHIBITION

14. FURTHER DESCRIPTION OF HOW SAMPLES WILL BE USED

15. DISPOSAL SITE (name and address where product will be disposed)

16. METHOD OF DISPOSAL (Describe the process of destruction/denaturing. For guidance refer to 9 CFR 325.13)

17. SIGNATURE OF BROKER OR APPLICANT (must be signed)

18 PRINTED NAME AND TITLE

20. DATE VERIFIED

19. SIGNATURE OF FSIS OFFICIAL WHEN VERIFIED

PREVIOUS EDITIONS ARE OBSOLETE
USDA - FSIS
FSIS 9540-5 (01/12/2023)
DISTRIBUTION: Prior to importing the product, the importer/broker/applicant must submit a copy of FSIS Form 9540-5 to the FSIS Recall Management and Technical Analysis
Division (RMTAD) at [email protected] .
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INSTRUCTIONS FOR PREPARATION OF FSIS FORM 9540-5
Note: The information on the form can be typed or written.
Submit Form: The form may be printed and scanned or saved as a .pdf and emailed to: [email protected]
1. U.S. Port of Entry - the port where the shipment will enter the United States (City and State)
2. Country of Origin - the country reflected on the sample shipping cartons and individual packages inside the shipping containers as labeled
3. Foreign Est. Number - the number of the producing establishment in the foreign country, if applicable
4. Date of Notification - date this form was submitted to FSIS
5. Name and address of Importer - the name and full address (including state and zip code) of the person/company who is importing this product
6. Name, address, phone number of Customs Broker or Applicant - the name of a person, full address (including state and zip code) and phone
number who is completing this form
7. Name, address, phone number of Consignee - the name of a person, full address (including state and zip code) and phone number who is receiving
this product
8. Address, phone number where the samples will be shipped - full address (including state and zip code) and phone number of the location where
the product will be shipped (if different from the consignee in block 7)
9. Name of product and species derived from - detailed product name and the species (e.g., beef, goat, lamb, pork, chicken, duck, goose, turkey)
(You may add an addendum if more than one item is or species). If the product is derived from animal cell culture technology, this must be
indicated in the product description (e.g., Raw ground non-intact cell-cultured beef)
10. Net weight - weight of shipment, in avoirdupois (pounds) and include amount per weight of species
11. Number of cartons or units - total number of cartons
12. Type/method of packaging - e.g., carton, pouch, cryovac, pails, etc.
13. Intended use of samples - check one or more of the choices; Laboratory Examination, Research, Evaluative Testing, Trade Show Exhibition
Definitions:
Laboratory Examination - an examination conducted under scientific conditions in a laboratory or similar setting with testing done at laboratory
for various information such as protein content, nutrients, etc.
Research - a studious inquiry or examination especially investigation or experimentation aimed at the discovery and interpretation of facts, or
revision of accepted facts. Examples include proficiency food safety testing, testing done for new products or variations of existing products,
flavor profile, a new formulation or flavor, and re-producing a particular flavor, etc.
Evaluative Testing - in house testing to determine the significance, worth or condition by careful appraisal and study evaluation. To be
accomplished through non-laboratory methods such as visual assessment of product and packaging, specifications evaluation, reheating
method, machine calibration and performance, comparison to domestic product, and sensory evaluation, etc.
Trade Show Exhibition - exhibition at an exposition to promote awareness and sales of products within an industry for display and viewing of
product at trade show exhibition location. These products are not to be consumed or given away at trade fairs since the imported products
haven't had the opportunity to be inspected by FSIS-USDA
14. Further description of how samples will be used - provide detail of how the samples will be used
15. Disposal site - company name and address (including state and zip code) where the product will be destroyed
16. Method of disposal - detailed method of destruction/disposal
17. Signature of Broker or Applicant (must be signed) - the signature of the broker or applicant (must be signed)
18. Printed name and Title - the name and the title of the broker or applicant
BLOCKS 19 AND 20 FOR FSIS PERSONNEL USE ONLY
19. Signature of FSIS Official when verified - signature of the FSIS personnel who verified this shipment
20. Date verified - the date the shipment was verified
FSIS 9540-5 (01/12/2023)

PREVIOUS EDITIONS ARE OBSOLETE
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USDA - FSIS