Form Approval: OMB No. 0910-0502; Expiration date: 8/31/2019; See OMB Statement below.
DEPARTMENT OF HEALTH AND HUMAN SERVICES FDA USE ONLY
Food and Drug Administration
DHHS/FDA CANCELLATION OF FOOD FACILITY REGISTRATION
(If entering by hand, use blue or black ink only.)
Facility Registration Number:
DOMESTIC REGISTRATION FOREIGN REGISTRATION
PIN:
FACILITY NAME / ADDRESS INFORMATION
Facility Name
Facility Street Address, Line 1
Facility Street Address, Line 2
City State (If applicable; if not, Province/Territory (If applicable)
skip to Province/Territory)
ZIP or Postal Code Country
CERTIFICATION STATEMENT
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.
Signature of Submitter Printed Name of Submitter
INFORMATION ABOUT INDIVIDUAL SUBMITTING THE CANCELLATION
Street Address, Line 1
Street Address, Line 2
City State (If applicable; if not, Province/Territory (If applicable)
skip to Province/Territory)
ZIP or Postal Code Country
E-Mail (If available)
Check One Box A. OWNER, OPERATOR OR AGENT IN CHARGE B. INDIVIDUAL AUTHORIZED TO SUBMIT THE
(STOP HERE, FORM IS COMPLETED) CANCELLATION (FILL IN BELOW)
If you checked Box B above, indicate who authorized you to submit the cancellation.
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
Authorizing Individual Street Address, Line 2
City State (If applicable; if not, Province/Territory (If applicable)
skip to Province/Territory)
ZIP or Postal Code Country Phone Number (Include Area/Country Code)
E-Mail (Required unless FDA has granted a waiver under 21 CFR 1.245)
FORM FDA 3537a (8/16) PSC Publishing Services (301) 443-6740 EF
MAIL COMPLETED FORM FDA 3537a TO U.S.
FOOD AND DRUG ADMINISTRATION, FDA USE ONLY
FOOD FACILITY REGISTRATION, 5001 Date Registration Form Received Date Notification Sent to Facility
CAMPUS DRIVE, HFS-681, COLLEGE PARK,
MD 20740 OR FAX IT TO 301-436-2804
This section applies only to the requirements of the Paperwork Reduction Act of 1995: The Department of Health and Human Services
public reporting burden time for this collection of information is estimated to average 1 hour per Food and Drug Administration
response, including the time to review instructions, search existing data sources, gather and Office of Operations
maintain the data needed and complete and review the collection of information. Send comments Paperwork Reduction Act (PRA) Staff
regarding this burden estimate or any other aspect of this information collection, including
[email protected] suggestions for reducing this burden to the address to the right:
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of Do not send your completed form to
information unless it displays a currently valid OMB control number. the above PRA Staff email address.
FORM FDA 3537a (8/16)
