Free FORM FDA 3537a - Federal

Form Approval: OMB No. 0910-0502; Expiration date: 5/31/2010; See OMB Statement below. DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

FDA USE ONLY

DHHS/FDA CANCELLATION OF FOOD FACILITY REGISTRATION
(If entering by hand, use blue or black ink only.) Facility Registration Number: PIN: Facility Name Facility Street Address, Line 1 Facility Street Address, Line 2 City ZIP or Postal Code State (If applicable; if not, skip to Province/Territory) Country Province/Territory (If applicable)

DOMESTIC REGISTRATION

FOREIGN REGISTRATION

FACILITY NAME / ADDRESS INFORMATION

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 Check One Box Printed Name of Submitter

A. OWNER, OPERATOR OR AGENT IN CHARGE
(STOP HERE, FORM IS COMPLETED)

B. INDIVIDUAL AUTHORIZED TO SUBMIT THE
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 ZIP or Postal Code State (If applicable; if not, skip to Province/Territory) Country Province/Territory (If applicable) Phone Number (Include Area/Country Code)

MAIL COMPLETED FORM FDA 3537a TO U.S. FOOD AND DRUG ADMINISTRATION, HFS-681, 5600 FISHERS LANE, ROCKVILLE, MD 20857, OR FAX IT TO 301-436-2804

FDA USE ONLY
Date Registration Form Received Date Notification Sent to Facility

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 (HFA-710) 5600 Fishers Lane Rockville, MD 20857

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.

FORM FDA 3537a (11/08)

PSC Graphics (301) 443-1090

EF