Form FDA 3733 FDA 3733 SHELL EGG PRODUCER REGISTRATION FORM

Form Approval: OMB No. 0910-xxxx

Expiration Date:

See OMB Statement at end of form

DHHS/FDA – SHELL EGG PRODUCER REGISTRATION FORM

FDA USE ONLY

U SE BLUE OR BLACK INK ONLY

Date: (MM/DD/YYYY)
Section 1 - TYPE OF REGISTRATION
1a. O DOMESTIC REGISTRATION	O FOREIGN REGISTRATION
1b. O INITIAL REGISTRATION O UPDATE OF REGISTRATION INFORMATION	O NOTIFICATION OF CEASING OPERATIONS AS OF DATE: (MM/DD/YYYY)
1c. If update or ceasing operations notification, provide the following: Facility Registration Number: ______________________________ PIN___________________________
1d. If update, check all that apply and further identify changes in the applicable sections.	O Preferred Mailing Address Change
O Facility Name Change	O Seasonal Facility Dates of Operation Change
O Facility Address Change (see instructions)	O Operator or Agent in Charge Change
1e. ARE YOU THE NEW OWNER OF A PREVIOUSLY REGISTERED FACILITY? Yes O No O 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:
FACILITY STREET ADDRESS, Line 2:
CITY:	STATE:
ZIP CODE (POSTAL CODE):	PROVINCE/TERRITORY:
COUNTRY:	PHONE NUMBER (Include Area/Country Code):
FAX NUMBER (OPTIONAL; Include Area/ Country Code):	E-MAIL ADDRESS (OPTIONAL):
Section 3 (OPTIONAL) - PREFERRED MAILING ADDRESS INFORMATION complete this section only if different from Section 2, Facility Name/Address Information
NAME:
ADDRESS, Line 1:
ADDRESS, Line 2:
CITY:	STATE:
ZIP CODE (POSTAL CODE):	PROVINCE/TERRITORY:
COUNTRY:	PHONE NUMBER (Include Area/ Country Code):
FAX NUMBER (Include Area/ Country Code):	E-MAIL ADDRESS:
Section 4 - 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
PROVIDE THE FOLLOWING INFORMATION, IF DIFFERENT FROM ALL OTHER SECTIONS ON THE FORM. IF INFORMATION IS THE SAME AS ANOTHER SECTION OF THE FORM, CHECK WHICH SECTION: SECTION 2 O SECTION 3 O
STREET ADDRESS, Line 1:
STREET ADDRESS, Line 2:
CITY:	STATE:
ZIP CODE (POSTAL CODE):	PROVINCE/TERRITORY:
COUNTRY:	PHONE NUMBER (Include Area/Country Code):
FAX NUMBER (OPTIONAL; Include Area/ Country Code):	E-MAIL ADDRESS (OPTIONAL):
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 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 THE SUBMITTER
CHECK ONE BOX: O A. OWNER OR OPERATOR (STOP HERE, FORM IS COMPLETED) O B. INDIVIDUAL AUTHORIZED TO SUBMIT THE REGISTRATION (FILL IN BELOW)
IF YOU CHECKED BOX B ABOVE, INDICATE WHO AUTHORIZED YOU TO SUBMIT THE REGISTRATION: O OWNER OR OPERATOR (STOP HERE, FORM IS COMPLETED) O ____________________________________________________________ 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:
CITY:		STATE:
ZIP CODE (POSTAL CODE):		PROVINCE/TERRITORY:
COUNTRY:		PHONE NUMBER (Include Area/Country Code):
FAX NUMBER (OPTIONAL; Include Area/ Country Code):		E-MAIL ADDRESS (OPTIONAL):

MAIL COMPLETED FDA FORM 3733 TO U.S. FOOD AND DRUG ADMINISTRATION, 10903 NEW HAMPSHIRE AVENUE, SILVER SPRING, MD 20993, OR FAX IT TO (301) 436-2599.

FDA USE ONLY
DATE REGISTRATION FORM RECEIVED	DATE NOTIFICATION SENT TO FACILITY
CHECK ONE BOX INDICATING FACILITY STATUS:	O ACTIVE O 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 (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.

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Form 3733 (7/09)