FSIS FORM 5200-2 - APPLICATION FOR FEDERAL INSPECTION

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FSIS FORM 5200-2, APPLICATION FOR FEDERAL INSPECTION
(Meat, Poultry, Siluriformes Fish, Egg Products, and Import)

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INSTRUCTIONS FOR COMPLETION OF FSIS FORM 5200-2
Complete all sections. Enter N/A if a section is not applicable. Use continuation sheet if needed on Page 7 and number the item. To submit electronically,
access the FSIS Form 5200-2, Application for Federal Inspection, on the https://www.fsis.usda.gov/employees/hr-policies-systems/forms page. Complete the
electronically-fillable form and save the form on your hard drive. Print the form and sign it. Scan the form and e-mail the completed form to the Grant Curator in
the appropriate District Office. For paper copies, send the signed application form to the Grant Curator at the District Office mailing address.
SECTION I. APPLICANT INFORMATION - (Page Three)
1.

Date of Application: Put current date application is completed.

1a. Existing Establishment Number, if applicable.
2.

Type of Application (check all that apply).

3.

Type of Inspection (check all that apply).

4.

Form of Organization (check applicable box).

5.

If Corporation, Name of State where Incorporated.

6.

Date Incorporated: Show month, date, and year, e.g., mm/dd/yyyy.

7.

Name and Address of Corporate Headquarters.

8.

Federal Employer ID #.

9.

Dun & Bradstreet #, if applicable.

10.

Firm's Code (Import Only).

11.

Name of Applicant (person, firm, or corporation making application) and mailing address.

12.

Telephone number and e-mail address of applicant.

13.

Actual Name of Company and Physical Location Address of Establishment.

14.

Telephone number and e-mail address of establishment.

SECTION II. ESTABLISHMENT INFORMATION - (Page Three)
15.

Establishment Limits: Provide a diagram, schematic or written narrative of the establishment premises that is requested to be under Federal inspection.

16.

Name and establishment number of other official establishments located in the same facility, if applicable.

17.

Other names - Doing Business As (DBA). Use continuation sheet if necessary.

18.

Month and year when establishment will be ready to operate under inspection.

SECTION Ill. TYPE OF OPERATIONS - Meat, Poultry, Siluriformes Fish, Egg Products, and Import Inspection - (Page Four)
19A. For slaughter operations, check all applicable boxes of animals to be slaughtered at the establishment. For cell-cultured operations, check all applicable boxes
of animal cells to be harvested at the establishment.
19B. Check all applicable boxes for the types of products intended for processing operations at the establishment.
19C. Check all applicable boxes to indicate the type of exempt activities and provide an attachment to explain how the activities will be separated by time or by space.
19D. Check all applicable boxes under JURISDICTION
20.

Check all applicable boxes (EGG PRODUCTS INSPECTION ONLY)

21A. Check all applicable boxes for Species (IMPORT INSPECTION ONLY)
21B. Check all applicable boxes for Mode of Transportation (IMPORT INSPECTION ONLY)
21C. and 21D. Check all applicable boxes Types of Products (IMPORT INSPECTION ONLY)

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT - (Pages Five and Six)
22.

The applicant must provide a list of persons responsibly connected with the establishment Include all partners, officers, directors, holders, or owners if 10% or more of its
voting stock or employees in a managerial or executive capacity. Check the appropriate box for 10% or more voting stock. Use continuation sheet or provide an attachment,
if necessary.

23.

Self-explanatory. If none, check the None box. If yes, check the Yes box and explain.

24.

Self-explanatory. If none, check the None box. If yes, check the Yes box and explain.

25.

Have conditions for receiving inspection been met (SSOP, Recall Procedures, HACCP) in accordance with 9 CFR 304.3 and 381.22? Check all applicable boxes.

26.

Privacy Act Notice. Check appropriate box.

PLEASE READ AGREEMENT, CERTIFICATION, AND WARNING STATEMENT
27.
28.

Typed or written name and title of person signing application. (Must be listed in Block 22).
Signature: By signing your name in this block you are stating that the information provided is accurate and binding.

BLOCKS 29, 30, 31, 32, AND 33 - TO BE COMPLETED BY USDA, FSIS, OFO DISTRICT OFFICE ONLY

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UNITED STATES DEPARTMENT OF AGRICULTURE (USDA)
FOOD SAFETY AND INSPECTION SERVICE (FSIS)
OFFICE OF FIELD OPERATIONS (OFO)

PRIVACY ACT NOTICE
The Privacy Act of 1974 (5 U.S.C. 522A) requires that certain information be given to you when you are
requested to furnish personal information to a Government Agency. The required information is provided in this
Notice. The act does not apply, however, to business information about your firm.

AUTHORITY FOR REQUESTING INFORMATION
Authority for requesting both personal and business information is contained in the Federal Meat Inspection Act
(21 U.S.C.601 et seq.) and the Poultry Products Inspection Act (21 U.S.C. 451 et seq.). Under these Acts, the
Secretary of Agriculture is authorized to determine the fitness of applicants for or recipients of inspection service
to engage in business requiring inspection. Your disclosure of personal information to aid in this determination is
mandatory. The Acts also require full and complete disclosure of records and information showing the
transactions of your business.

PURPOSE FOR WHICH THE INFORMATION WILL BE USED
This information is being requested to establish and record your identity as a responsible official of the business
and to determine your fitness to receive a Grant of Inspection.

ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION
In appropriate situations, a report containing the information you furnish may be referred to other federal, state,
local or foreign agencies charged with law enforcement or the investigation or prosecution of law violations.

EFFECTS OF FAILURE TO FURNISH INFORMATION
Failure to provide requested information may delay or interfere with your receiving inspection service and may
result in civil penalties of $100.00 per day against you or your business, as prescribed by (15 U.S.C. 50). In
addition, persons making false, fictitious, or fraudulent statements or entries are subject to a $10,000.00 fine or
imprisonment for not more than 5 years or both, as prescribed by (18 U.S.C 1001).

This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, religion, sex, national origin,
age or disability, immediately contact USDA, Office of the Assistant Secretary for Civil Rights, 1400 Independence Ave., S.W., Stop
9410, Washington, DC 20250-9410, Toll-Free: (866) 632-9992, Federal relay: (800) 877-8339, Spanish relay: (800) 845-6136, Fax: (202)
690-7442, Email: [email protected]

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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 0583-0153. The time required to complete this information collection is estimated to average 10 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

APPLICATION FOR FEDERAL INSPECTION

(Meat, Poultry, Siluriformes Fish, Egg Products and Import Inspection)
SECTION I.

Submit this application electronically, or by mail, to the Grant Curator at the appropriate
U.S. Department of Agriculture, Food Safety and Inspection Service, District Office.
Complete all sections. If a section is not applicable, enter N/A or None. If additional
space is needed for any items, use the continuation sheet provided or an attachment.
Number the item.

APPLICANT INFORMATION

1. Date of Application

1a. Existing Establishment Number (if applicable)

2. Type of Application (check all that apply)
Change of Location

New

Other, specify:

Change of Ownership

3. Type of Inspection (check all that apply)
Poultry

Meat

Egg Products

Import

Siluriformes Fish

Cell-Cultured

4. Form of Organization (check applicable box)
Cooperative
Association

Individual

5. If Corporation, Name of State or
Territory where Incorporated

Partnership

Corporation

6. Date Incorporated

Limited Liability
Company (LLC)

Other

7. Name and Address of Corporate Headquarters
Name

mm/ dd/ yyyy
8 Federal Employer ID#

Education Institution

9. Dun & Bradstreet # (if applicable)

Address
City

10. Firm's Code (Import Only)

Zip
Code

State

Country

11. Name of Applicant (person, firm or corporation making application) and mailing 12. Telephone number and e-mail address of applicant
address
Name
phone
Address

e-mail

City
State

Zip
Code

Country

13. Actual Name of Company and Physical Location Address of Establishment

14. Telephone number, mailing address and e-mail address of establishment

Name

phone

Address

mailing
address

City

State

Zip
Code

SECTION II.

e-mail
Country

ESTABLISHMENT INFORMATION

15. Establishment Limits: Provide a diagram, schematic or written narrative of the establishment premises that is requested to be under Federal inspection. Use
continuation sheet or attachment if necessary.
on continuation sheet

attached document

by other means (mail, courier)

previously submitted

16. Name and establishment number of other official establishments located in the 17. Other names - Doing Business As (DBA) - Use continuation sheet
same facility (if applicable)
if necessary

18. Estimated date when the establishment will be ready to operate under
inspection (mm/ dd/ yyyy)
FSIS FORM 5200-2 (01/18/2023)

Previous Editions are Obsolete

Page 4

SECTION III. TYPE OF OPERATIONS
19. MEAT, POULTRY, AND SILURIFORMES FISH INSPECTION ACTIVITIES (check all that apply)
19A. SLAUGHTER OR
HARVEST OPERATIONS

19B. PROCESSING
OPERATIONS

19C. EXEMPTIONS (explain separation
from inspected products on continuation
sheet)

19D. JURISDICTION (explain
separation from inspected
products on continuation sheet)

Calf

a.

Fully Cooked - Not Shelf Stable

Custom Processing

FSIS Inspection only

Cattle

b.

Heat Treated Not Fully Cooked Not Shelf Stable

Custom Slaughter

State Inspection

c.

Heat Treated - Shelf Stable

Retail Activities

Talmadge-Aiken

d.

Not Heat Treated - Shelf Stable

e.

Product with Secondary
Inhibitors - Not Shelf Stable

Equine
Goat
Sheep
Swine
Chicken

f.

Raw - Intact Products

Duck

g.

Raw - Non Intact Products

Goose

h.

Thermally Processed
Commercially Sterile

Guinea

Religious Exempt Poultry

Multiple Agencies
N/A

Buddhist eviscerated Poultry

Dual Jurisdiction
Establishment with Food
and Drug Administration
(FDA)

Confucian Non-eviscerated
Poultry
Islamic (Halal) Poultry

USDA Agricultural
Marketing Service
(AMS) Grading/Quality
Control

Kosher Non-eviscerated Poultry

Ratite

Religious Exempt Livestock

Squab

Establishment provides
products for the National
School Lunch Program

Halal

Turkey

Kosher

Siluriformes Fish

Other (specify on continuation
sheet)

20. EGG PRODUCTS INSPECTION (check all that apply)
a. Fully Cooked - Not Shelf Stable

b. Heat Treated - Shelf Stable

d. Egg Breaking

c. Raw - Non-Intact

21. IMPORT INSPECTION (check all that apply)
21A. Species
Meat

21C. Types of Products
(egg products)

Poultry

Liquid Eggs

Egg Products

Frozen Eggs

Siluriformes Fish

Dried Eggs

21D. Types of Products (meat and poultry only)

Fully Cooked - Not Shelf Stable
Frozen from an APHIS restricted
country 9 CFR 94.4 (b)
Frozen
Perishable
Heat Treated - Not Fully Cooked Not Shelf Stable

21B. Mode of Transportation

Heat Treated - Shelf Stable

Rail Cars

Not Heat Treated - Shelf Stable

Ocean Vessel

Product with Secondary Inhibitors Not Shelf Stable

Trucks
Airline
Other,
specify:

FSIS FORM 5200-2 (01/18/2023)

Raw - Non-Intact
Ground product
Other Non-intact

Previous Editions are Obsolete

Raw - Intact
Cuts (including bone-in
and boneless meats)
Boneless and/or skinless parts
Other Intact
Carcasses
Beef

Equine

Goat

Lamb

Mutton

Pork

Poultry

Ratite

Veal

Veal-hide on

Thermally Processed/Commercially
Sterile
Soups

Corned (species)

Other

Ham

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT

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22. The applicant must provide a list of persons responsibly connected with the establishment. Include all partners, officers, directors, holders, or owners of 10 percent or
more of voting stock or employees in a managerial or executive capacity. Check the appropriate box for 10% or more voting stock. Use continuation sheet or provide an
attachment if necessary.

Name and Title

Present e- mail and home address

First

e-mail

Last

Address

Holder of 10% or more voting
stock? (if corporation)
yes
no

City
Title

First
Last

State

Zip
Code

Country

e-mail

yes

Address

no

City
Zip
Code

Title

State

First

e-mail

yes

Last

Address

no

Country

City
Zip
Code

Title

State

First

e-mail

yes

Last

Address

no

Country

City
Title

State

First

e-mail

Last

Address

Zip
Code

Country
yes
no

City
Zip
Code

Title

State

First

e-mail

yes

Last

Address

no

Country

City
Title

FSIS FORM 5200-2 (01/18/2023)

State

Zip
Code

Country

Previous Editions are Obsolete

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT (continued)

Page 6

23. Enter the name of each person listed in Block 22 who has been convicted in any Federal or state court of (1) any felony, or (2) more than one violation of any
law, other than a felony, based upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or fraud in connection with
transactions in food. Include the nature of the crime(s), indicate felony/misdemeanor, the date of the conviction and the court in which convicted. If none, check
the box. If yes, check the yes box and explain. Use continuation sheet if necessary.

None

Yes, explain

24. List each conviction against the applicant or recipient (person, firm or corporation) in any Federal or state court of any (1) felony, or (2) more than one
violation of any law, other than a felony, based upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or
upon fraud in connection with transactions in food. Include the nature of the crime(s), indicate felony/misdemeanor, the date of conviction and the court in which
convicted. If none, check the box. If yes, check the yes box and explain. Use continuation sheet if necessary.
None

Yes, explain

25. Check appropriate boxes if conditions for receiving inspection have been met in accordance with 9 CFR 304.3, 381.22, and 590.149 for meat, poultry, and
egg products inspection only. Check all applicable boxes.
Developed written Sanitation Standard
Operating Procedures (SSOP)

Developed written recall procedures

(Does not apply to egg product inspection.)

Conducted a hazard analysis and developed a
Hazard Analysis and Critical Control Point
(HACCP) plan

26. Applicant has been provided with a copy of the Privacy Act Notice?
Yes

No

AGREEMENT AND CERTIFICATION: If inspection is granted under the application, I (we) expressly agree to conform strictly to the Federal Meat Inspection Act
(21 U.S.C. 601 et seq.), or the Poultry Products Inspection Act (21 U.S.C. 451 et. seq.), or the Egg Products Inspection Act, (21 U.S.C. 1031 et. seq.), and the
regulations governing the inspection of the meat, poultry or egg product inspection of the United States Department of Agriculture (9 CFR Part 301 et. seq.). I
CERTIFY that all statements made herein are true to the best of my knowledge and belief.
WARNING: Persons knowingly and willfully making false, fictitious, or fraudulent statements or entries are subject to $10,000 fine or imprisoned not more than
five years, or both, as prescribed by Title 18 U.S.C. 1001. This is an Equal Opportunity Program. If you believe you have been discriminated against because of
race, color, religion, sex, national origin, age or handicap, write immediately to the Secretary of Agriculture or the Administrator, FSIS, Washington, DC 20250.
27. Typed or written
name and title of person
signing application

28. Signature

TO BE COMPLETED BY USDA FSIS OFO DISTRICT OFFICE ONLY
29. Is this establishment:
(check all that apply)

30. Date application
received by District Office

under State Inspection?

in the Cooperative Interstate
Shipment (CIS) Program?

31. Official inspection number(s)
assigned by District Office

32. Signature of the
District Manager

FSIS FORM 5200-2 (01/18/2023)

to be under the TalmadgeAiken Act?

33. Date

Previous Editions are Obsolete

Continuation Sheet for FSIS FORM 5200-2

FSIS FORM 5200-2 (01/18/2023)

Previous Editions are Obsolete

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