FORM FDA 3537a

DHHS/FDA Cancellation of Food Facility Registration

DHHS/FDA, Cancellation, of, Food, Facility, Registration

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Form Approval: OMB No. 0910-0502; Expiration date: 8/31/2022; 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

DOMESTIC REGISTRATION FACILITY NAME / ADDRESS INFORMATION

FOREIGN REGISTRATION

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)

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

Street Address, Line 1

INFORMATION ABOUT INDIVIDUAL SUBMITTING THE CANCELLATION

Street Address, Line 2

City ZIP or Postal Code

State (If applicable; if not, skip to Province/Territory)
Country

Province/Territory (If applicable)

E-Mail (If available)

Check One Box

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

If you checked Box B above, indicate who authorized you to submit the cancellation.

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

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)

E-Mail (Required unless FDA has granted a waiver under 21 CFR 1.245)

FORM FDA 3537a (8/19)

PSC Publishing Services (301) 443-6740 EF

MAIL COMPLETED FORM FDA 3537a TO U.S. FOOD AND DRUG ADMINISTRATION, FOOD FACILITY REGISTRATION, 5001
CAMPUS DRIVE, HFS-681, COLLEGE PARK, MD 20740 OR FAX IT TO 301-436-2804

FDA USE ONLY

Date Registration Form Received

Date Notification Sent to Facility

This section applies only to the requirements of the Paperwork Reduction Act of 1995: The public reporting burden time for this collection of information is estimated to average 1 hour per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including 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 information unless it displays a currently valid OMB control number.

Department of Health and Human Services Food and Drug Administration Office of Operations Paperwork Reduction Act (PRA) Staff PRAStaff@fda.hhs.gov
Do not send your completed form to the above PRA Staff email address.

FORM FDA 3537a (8/19)