7234-1 Application for Approval of Labels, Marking or Device

OMB Control Number 0583-0092
Expiration Date:
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U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

APPLICATION FOR
APPROVAL OF LABELS,
MARKING OR DEVICE

1. AGENT NAME, ADDRESS,
TELEPHONE NO. (If using an Agent,
complete this block, otherwise leave
blank.)

2. FOR USDA USE ONLY

3. FOR USDA USE ONLY

of

4. ESTABLISHMENT NO. / FOREIGN
COUNTRY (If applicable)

4a. TYPE OF PRODUCT

FSIS has determined that information provided
in items 11, 15, and 16 is exempt from
mandatory disclosure under the Freedom of
Information Act 5 U.S.C. 552(b)(4).
APPLICANT: See Page 5 for instructions.

Egg

Meat

Poultry

Other

5a. NAME OF PRODUCT
5b. HACCP PROCESS CATEGORY

(Select one)

SKETCH

03B: Raw Product - ground

EXTENSION OF TEMPORARY

03C: Raw Product - not ground
03D: Thermally processed - commercially sterile
03F: Heat treated - shelf stable
03G: Fully cooked - not shelf stable

YES

Prior approval number:

NO

Number of labels on hand:
Number of days requested:

03I: Product with secondary inhibitors - not shelf stable
8. Does this label include a "USDA-AMS Child Nutrition Program CN-Logo?
10. Are there any special claims, guarantees, or foreign language on the label?

Certified/Verified
Environmental/Green
Export Only Labels w/deviations from Domestic Requirements

9. (FOR USDA-AMS USE ONLY) CN Identification Number Assigned

Yes

No

YES

NO (If yes, check all that apply)
Other Claims: Specify

Grading Terms
Guarantees
Natural/Organic

Foreign Language

Nutrition/Health

Geographic/Undefined Style

Religious Exemption

11. NAME AND ADDRESS OF FIRM (Below and between dots)

7b. TOTAL AVAILABLE LABELING SPACE FOR ENTIRE PACKAGE (Square inches):

► Date of approval:

03H: Heat treated but not fully cooked - not shelf stable

Animal Production/Breed/Raising

TEMPORARY

6b. WAS THE LABEL PREVIOUSLY APPROVED?

03E: Not heat treated - shelf stable

Allergen Statements

7a. AREA OF PRINCIPAL DISPLAY PANEL (Square Inches)

6a. TYPE OF APPROVAL REQUESTED

03J: Slaughter - all species

12. SIGNATURE OF APPLICANT OR AGENT

13. DATE

14. (FOR USDA USE ONLY) CONDITIONS APPLYING TO USE OF LABELS OR DEVICE

FSIS FORM 7234-1 (11/16/2011)

REPLACES FSIS FORM 7234-1 (09/01/2009), WHICH IS OBSOLETE.

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FSIS FORM 7234-1 (11/16/2011) page 2
PCT

15. PRODUCT FORMULA

WEIGHT

(No Fractions)

See Continuation Sheet

TOTAL

(Percent must total 100%)

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FSIS FORM 7234-1 (11/16/2011) page 3

16. PROCESSING PROCEDURES (Approval of the sketch does not convey approval of the processing procedures)

See Continuation Sheet

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FSIS FORM 7234-1 (11/16/2011) page 4

CONTINUATION SHEET FOR APPLICATION FOR APPROVAL OF LABELS,
MARKING OR DEVICE (FSIS 7234-1)
PRODUCT NAME:

This sheet is being used for additional information required in Block(s):

of

INSTRUCTIONS FOR PREPARATION OF FSIS FORM 7234-1
Note: The following instructions should be typed unless otherwise noted.
A.

B.

PREPARATION OF APPLICATION
Application must be typed or it will be returned without evaluation.
Submit two copies for each label application.
TYPE OF APPROVAL REQUESTED
Sketch: Self explanatory. (See 9 CFR 317.4 & 381.132)
Temporary and Extension of Temporary. Actual label or color litho take off to be used.

C.

D.

E.

Total available labeling space in square inches for entire package.

8.

USDA-AMS Child Nutrition Program Logo. Indicate if the product
includes a USDA-AMS Child Nutrition Program Logo.

9.

Leave Blank. For USDA-AMS use only.

10.

Special claims, guarantees, or foreign language. Indicate if there are
are any special claims, guarantees, or foreign language on the label.

FOREIGN LANGUAGE
Labels printed in foreign languages must be accompanied by English language translation.

Check all that apply. If Other Claims is selected, indicate specific claim(s)
in space provided.

ASSEMBLY OF APPLICATION

11.

Application Form, Product Formula, Processing Procedures, Continuation Sheet if applicable, Label,
and any Supporting Documentation Staple with one or as few staples as possible. (Do not use paper
clips).

Name and Address of Firm. Insert Firm's name and mailing
address. Use 2 letter symbol for State. Show postal zip code.

12 & 13.

Signature and Date of Applicant or Agent. To be signed and
dated by the applicant or agent representing the official
establishment or plant.

MAIL COMPLETED APPLICATION TO:
USDA, FSIS, OPPD, LPDD
Labeling Distribution Unit
Stop Code 3786, Patriots Plaza III, 8-168
1400 Independence Avenue, SW
Washington, DC 20250-3700

The following instructions relate to numbered items on form.
1.

If using an Agent, provide the company name, address, and telephone number,
otherwise leave blank.

2 & 3.

Leave blank, for USDA use only.

4.

Establishment No./Foreign Country (if applicable) - Self Explanatory.

4a.

Type of Product. Select one product type: Egg, Meat, Poultry, or Other (i.e. Exotic Species,
Non-Amenable, Voluntary, etc.)

5a.

Name of Product. Use common or descriptive product name, i.e., "Frankfurter ,
Cereal Added" or "Meat Patties in Gravy. (Do not use trade brand names or
coined names, such as "Joe's Corn Dogs" or "Joe's Sloppy Joes.") If coined
names such as "Corn Dogs" are used, also show true product name, such as
"Batter Wrapped Wiener."

5b.

Provide HACCP process category for the product. See 9 CFR 417.2(b) (1),
Example, Heat Treated - shelf stable, Not heat treated-shelf stable etc. Select one.

6a & b.

Type of Approval Requested. If temporary approval or extension, insert
number of days requested and number of labels on hand. If previous
approval, attach copy of application and label. Include specific reason(s)
why requesting a temporary or extension and include information required
in 9 CFR 317.4(f) (1) or 381.132(f) (1) on the continuation sheet.
Be sure to include product name and block item.

7a.

7b.

Area of Principal Display Panel (PDP). The PDP is the entire side
of the package to which the label is affixed. See 9 CFR 317.2 (d)
and 381.116 (b).
FSIS FORM 7234-1 (11/16/2011)

14.

15.

Leave blank for USDA use only. Conditions Applying to Use of Label or
Device. (Any condition, modification or remarks applied to the application
when approved are conditions governing use of the approved devices.)

Product Formula. List the ingredients by percent or weight in order of
their predominance. If product consists of several components, e.g.,
a frozen dinner, list each component separately and indicate the
percentage or amount of each component in the product. If additional
space is needed, check the box for "Continuation Sheet," and use the
Continuation Sheet. Be sure to include the product name and number
of the block item. Express all ingredients in the same units, i.e., do not
list some in pounds and others in ounces.
Check whether weight or percent is used. It is preferred that
percentages be used, and the total must equal 100 percent. If weights
are used, show in pounds, kilograms or grams. (No gallons, pints,
cups, teaspoons, etc.) The total must equal the weights of the
individual units. (Example: Crust + Cheese + Sauce + Meat = Total
new weight of unit.)
DO NOT use fractions. Express as decimals carried to two places, Example:
1-1/4 lbs., show as 1.25 lbs. Example: 3/4 lbs., show as .75 lbs.

16.

Processing Procedures. Poultry Products provide complete
processing procedures as required in 9 CFR 381.134. Meat
Products, provide complete processing procedures as required.
Note: Approval of the sketch does not convey approval of the
processing procedures. If additional space is needed, check the box for
"Continuation Sheet," and use the Continuation Sheet.
Be sure to include the product name and number of the block item.