9540-5 Notification of Intent to Import Meat Poultry or Egg Pro

OMB Control Number: 0583-0161
Expiration Date: 06/30/2025
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0583-0161. The time required to complete this information collection 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.
U.S. 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: (City, State)

2. Country of Origin: (If applicable)

3. Foreign Establishment Number: (If applicable)

4. Date of Notification:
(mm/dd/yyyy)

5. Name and Address of Importer:

6. Name, Address, Phone Number of Customs Broker or Applicant:

7. Name, Address and Phone Number of Consignee:

8. Address, Phone Number to Where the Samples will be Shipped:
(If different from consignee, block 7.)

9. Name of Product and Species Derived From:

10. Net Weight: (Pounds)

11. Number of Cartons or Units:

12. Type/Method of Packaging:

13. Intended Use of Samples: (Check all that apply)
Laboratory Examination

Research

Evaluative Testing

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)

19. Signature of FSIS Official When Verified:

18. Printed Name and Title:

20. Date Verified: (mm/dd/yyyy)

DISTRIBUTION: Prior to importing the product, the importer/broker/applicant must submit a copy of FSIS 9540-5 to the FSIS Recall Management and Technical Analysis Staff
(RMTAS) at [email protected].

FSIS 9540-5 (01/27/2025)

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INSTRUCTIONS FOR COMPLETING FSIS 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: (City and State) - The port where the shipment will enter the United States.
2. Country of Origin: The country reflected on the sample shipping cartons and individual packages inside the shipping containers as
labeled.
3. Foreign Establishment 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 a product 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 all that Apply) - 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.
18. Printed Name and Title: The name and the title of the broker or applicant.
Blocks 19. and 20. for 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 (01/27/2025)

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