10,110-2 Application for FSIS Accredited Laboratory Program

Application for FSIS Accredited Laboratory Program
US Department of Agriculture Food Safety Inspection Service Office of Public Health Science Accredited Laboratory Program Athens, GA 30605	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-xxxx. The time required to complete this information collection is estimated to average 30 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.
LABORATORY NAME:
STREET ADDRESS (PO Box alone not acceptable):
CITY: STATE: ZIP CODE:
NAME AND TITLE OF PRIMARY CONTACT: ________________________________________ ______________________________________________ NAME TITLE
PHONE NUMBER: FAX NUMBER:
EMAIL ADDRESS:
NAME AND TITLE OF OWNER/MANAGER: ________________________________________ ______________________________________________ NAME TITLE
1. ACCREDITATION REQUESTED		Yes No
A. FOOD CHEMISTRY (Moisture, Protein, Fat, and Salt) B. RESIDUE CHEMISTRY Chlorinated Hydrocarbons (CHC) Polychlorinated Biphenyls (PCB) Arsenic (As) Sulfonamides Nitrosamines		_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
2. IF YOUR LABORATORY IS CURRENTLY ACCREDITED BY THE FSIS ALP, PLEASE PROVIDE YOUR ALP LABORATORY NUMBER. _______________________________
3. HAS YOUR LABORATORY EVER BEEN PREVIOUSLY ACCREDITED BY THE ALP UNDER THE PRESENT OR A DIFFERENT NAME? (If no, proceed to section 5.)		Yes No _____ _____
If you answered yes in section 3, please provide the ALP laboratory number and the type of accredited analysis. _________________ ___________________________________________________________________________ ALP # ANALYSIS
4. WAS YOUR FSIS ALP ACCREDITATION EVER PLACED ON PROBATION AND/OR EVER REVOKED?		Yes No _____ _____
If you answered yes in section 4, please provide the most recent probation/revocation date: ________________________________
5. IS YOUR LABORATORY CURRENTLY ACCREDITED BY ANY OTHER STATE OR FEDERAL PROGRAM?		Yes No _____ _____
If you answered yes in section 5, please provide the name and description of the program(s). NAME: DESCRIPTION:
6. LABORATORY SUPERVISOR HAS A BACHELOR’S DEGREE OR HIGHER IN: Please enclose transcript or proof of degree. Proof is subject to verification with the degree granting institution.		Years Experience
Chemistry Food Science Food Technology Related Field (specify):		_____ _____ _____ _____ _____ _____ _____ _____
7. HAS THE LABORATORY OR ANY INDIVIDUAL OR ENTITY RESPONSIBLY CONNECTED WITH THE LABORATORY BEEN INDICTED OR HAVE CHARGES BEEN BROUGHT AGAINST THE LABORATORY OR RESPONSIBLY CONNECTED INDIVIDUAL OR ENTITY, IN A FEDERAL OR STATE COURT, CONCERNING ANY OF THE FOLLOWING VIOLATIONS OF LAW?		Yes No
A. Any felony. B. Any misdemeanor based upon acquiring, handling, or distributing of unwholesome, misbranded, or deceptively packaged food or upon fraud in connection with transactions in food. C. Any misdemeanor based on false statement to any government agency. D. Any misdemeanor based upon the offering, giving, or receiving of bribe or unlawful gratuity.		_____ _____ _____ _____ _____ _____ _____ _____
I certify that, to the best of my knowledge and belief, all information contained herein is true and understand that any willful falsification of this certification is a felony and may result in a fine of $250,000 or more for an individual or $500,000 or more for a corporation and imprisonment for not more than 5 years or both (18 USC 1001, 3571, and 3623). I have read the rules and requirements contained in 9 CFR Parts 391 and 439 and agree to abide by these rules and other requirements of the FSIS Accredited Laboratory Program.
SIGNATURE OR OWNER/MANAGER		DATE

TO BE COMPLETED BY ACCREDITED LABORATORY PROGRAM OFFICIALS
Fees paid?	Yes _____ No _____
On-site review required?	Yes _____ No _____
ACCREDITATION CHECK SAMPLES		Pass Fail
First Analysis Second Analysis		____ ____ ____ ____
OTHER SUPPORTING DOCUMENTATION NEEDED FOR REVIEW:
Approved _____		Denied (attach reason for denial) _____
LABORATORY NUMBER :
NAME OF REVIEWING OFFICIAL:
SIGNATURE			DATE

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FSIS FORM 10,110-2 (XX/XX) REPLACED FSIS FORM 10,110-2 (8/95) WHICH IS OBSOLETE