5200-6 Application Approval for Voluntary Reimbursable Inspecti

OMB Control Number: 0583-0153
Expiration Date:

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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 15 minutes per response, including the time for reviewing instructions, searching
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U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

APPLICATION/APPROVAL FOR VOLUNTARY REIMBURSABLE
INSPECTION SERVICE

INSTRUCTIONS: Submit this application to the District Manager, U.S. Department of Agriculture, Food
Safety and Inspection Service. Submit two sets of plans and four sets of specifications of the plant,
when required, as indicated below. Complete all sections. If a section is not applicable, enter "N/A". If
additional space is needed, use reverse side and number the item.

3. Est. Number Assigned/Reserved:

2. Type of Application:
New

1. Date of Application: (dd/mm/yyyy)

Change/Owner

Other (Specify):

Change/Location

5. Form of Organization:

4. Name of Applicant:

Indivisual

Coop. Assoc.

Corporation

Partnership

6. If Incorporated, give date of
Incorporation and state:
(dd/mm/yyyy)

Other (Specify):
7. Applicant''s Mailing Address: Street Address (up to 30 characters)

City: (up to 16 characters)

State:
(2)

Zip Code: (up to 11 numbers)

Phone: (123) 456-7890

9. Location of Plant if Different than Item 4: Street Address (up to 30 characters)

City: (up to 16 characters)

State:
(2)

Zip Code: (up to 11 numbers)

Phone: (123) 456-7890

REMARKS

SERVICE REQUESTED
11.

ID Service: Meat

COMPLETED BY USDA:
District Manager

AMS RTE Canada EV Program

ID Service: Poultry
12.

Certification:
Cysticercus

Certification:
Export

13.

Off-Premise
Freezing: Meat

Off-Premise
Freezing: Poultry

14.

Food Inspection: (requires plans and specs)

15.

Voluntary Meat & Poultry Slaughter/Processing

Off-Premise
Freezing: Egg
Products

S = SLAUGHTER

(Specify):

16.

Voluntary Egg Products Inspection/Processing
(Specify):

S-Antelope

P-Antelope

P-Elk

S-Bison

S-Other Poultry

P-Bison

P-Other Poultry

S-Buffalo/Water Buffalo

S-Rabbit

P-Buffalo/Water Buffalo

P-Rabbit

S-Cattalo/Catalo

S-Yak

P-Cattalo/Catalo

P-Yak

S-Quail

P-Deer/Reindeer

P-Quail

S-Pheasant
17.

Disapproved

Approved

Disapproved

Approved

Disapproved

Approved

Disapproved

Approved

Disapproved

Approved

Disapproved

Approved

Disapproved

P = PROCESSING
S-Elk

S-Deer/Reindeer

Approved

P-Pheasant

Technical Animal fats
(Specify):

AGREEMENT AND CERTIFICATION: If inspection service is granted under this application, I (we) expressly agree to conform strictly to the provisions of the Agricultural Marketing Act of 1946 (7 U.S.C. 1621 et
seq.) and the respective regulations thereunder. I certify that all statements made herein are true to the best of my knowledge and belief.
18. Type Name of Person Signing Application:

19. Signature of Owner, Partner or Authorized Officer:(making this
application)

20.Title:

21. Date: (dd/mm/yyyy)

COMPLETED BY USDA
22. Date Received: (dd/mm/yyyy)

FSIS 5200-6 (09/20/2023)

23. Date Facility Reviewed: (dd/mm/yyyy)

24. Est Number:

25. Signature of District Manager:

REPLACES FSIS FORM 5200-6 (02/17/2011), WHICH MAY BE USED UNTIL EXHAUSTED.

26. Date: (dd/mm/yyyy)