DHHS/FDA Cancellation of Food Facility Registration FORM FDA 3537a PSC Graphics

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Specifications	DHHS/FDA Cancellation of Food Facility Registration FORM FDA 3537a PSC Graphics
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FDA USE ONLY FACILITY NAME / ADDRESS INFORMATION The owner, operator, or agent in charge of the facility, or an individual au

Specifications	DHHS/FDA Cancellation of Food Facility Registration FORM FDA 3537a PSC Graphics
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Content	FDA USE ONLY FACILITY NAME / ADDRESS INFORMATION The owner, operator, or agent in charge of the facility, or an individual authorized by the owner, operator, or agent in charge of the facility, must submit this form. By submitting this form to FDA, or by authorizing an individual to submit this form to FDA, the owner, operator, or agent in charge of the facility certifies that the above information is true and accurate. An individual (other than the owner, operator, or agent in charge of the facility) who submits the form to FDA also certifies that the above information submitted is true and accurate and that he/she is authorized to submit the cancellation on the facility s behalf. An individual authorized by the owner, operator, or agent in charge must below identify by name the individual who authorized submission of the cancellation. Under 18 U.S.C. 1001, anyone who makes a materially false, fictitious, or fraudulent statement to the U.S Government is subject to criminal penalties. CERTIFICATION STATEMENT Facility Name Facility Street Address, Line 1 City Facility Street Address, Line 2 Province/Territory (If applicable)State (If applicable; if not, skip to Province/Territory) CountryZIP or Postal Code DOMESTIC REGISTRATIONFOREIGN REGISTRATIONPIN: Facility Registration Number: Printed Name of SubmitterSignature of Submitter (If entering by hand, use blue or black ink only.) DHHS/FDA CANCELLATION OF FOOD FACILITY REGISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration Form Approval: OMB No. 0910-0502; Expiration date: 8/31/2013; See OMB Statement below. Date Notification Sent to Facility FDA USE ONLY Date Registration Form Received FORM FDA 3537a (8/11) MAIL COMPLETED FORM FDA 3537a TO U.S. FOOD AND DRUG ADMINISTRATION, FOOD FACILITY REGISTRATION, 5100 PAINT BRANCH PARKWAY, HFS-681, COLLEGE PARK, MD 20993 OR FAX IT TO 301-436-2804 Public reporting burden for this collection of information is estimated to average 1 hour 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the address to the right. Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer 1350 Piccard Drive, Room 400 Rockville, MD 20850 An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Check One Box If you checked Box B above, indicate who authorized you to submit the cancellation. A. OWNER, OPERATOR OR AGENT IN CHARGE (STOP HERE, FORM IS COMPLETED) B. INDIVIDUAL AUTHORIZED TO SUBMIT THE CANCELLATION (FILL IN BELOW) OWNER, OPERATOR OR AGENT IN CHARGE (STOP HERE, FORM IS COMPLETED) - NAME OF INDIVIDUAL WHO AUTHORIZED CANCELLATION ON BEHALF OF OWNER, OPERATOR, OR AGENT IN CHARGE (FILL IN ADDRESS BELOW) Address Information for the Authorizing Individual Authorizing Individual Street Address, Line 1 City Authorizing Individual Street Address, Line 2 Province/Territory (If applicable)State (If applicable; if not, skip to Province/Territory) CountryPhone Number (Include Area/Country Code)ZIP or Postal Code PSC Publishing Services (301) 443-6740 EF
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Following Datasheets	UCM072080_1 (1 pages) UCM072759_1 (2 pages) UCM072770_1 (1 pages) UCM072772_1 (1 pages) UCM073395 (10 pages) UCM074720_1 (1 pages) UCM074728_1 (2 pages) UCM076724_1 (2 pages) UCM076727_1 (2 pages) UCM076778_1 (1 pages)
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