Form FDA - 3733 FDA - 3733 DHHS/FDA SHELL EGG PRODUCER REGISTRATION

Form Approval: OMB No. 0910-XXXX; Expiration date: xx/xx/xxxx; See Reporting Burden Statement on page 3.

FDA USE ONLY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

DHHS/FDA SHELL EGG PRODUCER REGISTRATION
(If entering by hand, use blue or black ink only.)
Date (mm/dd/yyyy)

Section 1 - TYPE OF REGISTRATION
1a.

DOMESTIC REGISTRATION

FOREIGN REGISTRATION

1b.

INITIAL REGISTRATION

UPDATE OF REGISTRATION INFORMATION

NOTIFICATION OF CEASING OPERATIONS AS OF DATE (mm/dd/yyyy) :
Facility Registration Number

1c.

If update or ceasing operations notification, provide
the Facility Registration Number.

1d.

If update, check all that apply and further identify changes in the applicable sections.
Facility Name Change

Seasonal Facility Dates of Operation Change

Facility Address Change (See instructions)

Size of Operation Change

Preferred Mailing Address Change

Owner or Operator Change

1e. ARE YOU THE NEW OWNER OF A PREVIOUSLY REGISTERED FACILITY?

Yes

No

If "Yes", provide the following information, if known.
Previous owner's name

Previous owner's registration number

Section 2 - FACILITY NAME / ADDRESS INFORMATION
Facility Name
Facility Street Address, Line 1

PROOF

Facility Street Address, Line 2
City

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

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

FORM FDA 3733 (5/10)

E-Mail Address (Optional)

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PSC Graphics (301) 443-1090

EF

Section 3 - (OPTIONAL) PREFERRED MAILING ADDRESS INFORMATION - Complete this section only if different
from Section 2, Facility Name/Address Information.
Name
Street Address, Line 1
Street Address, Line 2
City

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

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

E-Mail Address (Optional)

Section 4 - (OPTIONAL) SEASONAL FACILITY DATES OF OPERATION - Give the approximate dates that your
facility is open for business, if its operations are on a seasonal basis.
Dates of Operation

Section 5 - SIZE OF OPERATION
Average or usual number of layers in each poultry house

Number of poultry houses on the farm

Section 6 - OWNER OR OPERATOR INFORMATION
Name of Entity or Individual Who Is the Owner or Operator

PROOF
Provide the following information, if different from all other sections on the form. If the information is the same as another section of the form,
check which section.
SECTION 2

SECTION 3

Street Address, Line 1
Street Address, Line 2
City

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

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

FORM FDA 3733 (9/09)

E-Mail Address (Optional)

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Section 7 - CERTIFICATION STATEMENT
The owner or operator of the facility, or an individual authorized by the owner or operator 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 or
operator of the facility certifies that the above information is true and accurate. An individual (other than the owner or
operator of the facility) who submits the form to the FDA also certifies that the above information submitted is true and
accurate and that he/she is authorized to submit the registration on the facility's behalf. An individual authorized by the
owner or operator must below identify by name the individual who authorized submission of the registration. 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
Check One Box

A. OWNER OR OPERATOR (STOP HERE, FORM IS COMPLETED)
B. INDIVIDUAL AUTHORIZED TO SUBMIT THE REGISTRATION (FILL IN BELOW)
If you checked Box B above, indicate who authorized you to submit the registration.
OWNER OR OPERATOR (STOP HERE, FORM IS COMPLETED)
– NAME OF INDIVIDUAL WHO AUTHORIZED
REGISTRATION ON BEHALF OF OWNER OR OPERATOR (FILL IN ADDRESS BELOW)

Address Information for the Authorizing Individual
Authorizing Individual Street Address, Line 1
Authorizing Individual Street Address, Line 2

PROOF

City

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

Province/Territory (If applicable)

ZIP or Postal Code

Country

Phone Number (Include Area/Country Code)

FAX Number (Optional; Include Area/Country Code)

E-Mail Address (Optional)

MAIL COMPLETED FORM FDA 3733 TO U.S. FOOD AND DRUG ADMINISTRATION, 5600 FISHERS LANE,
HFS-681, ROCKVILLE, MD 20857, OR FAX IT TO (301) 436-2804
FDA USE ONLY
Date Registration Form Received

Date Notification Sent to Facility

Facility Status (Check one)
Active

Inactive

Public reporting burden for this collection of information is estimated to average 2.3 hours 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:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
1350 Piccard Drive, 420A
Rockville, MD 20850

FORM FDA 3733 (5/10)

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.

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