NOTE: Form FDA 3733 is used to register a farm, to provide an update to an existing registration, or to notify FDA that you are ceasing operations. The owner or operator of the facility, or an individual authorized by the owner or operator of the facility, such as an agent in charge, must fill out, sign, and submit this form.
An individual (other than the owner or operator) who submits this form to FDA must, in section 7 of the form (certification statement), identify by name the individual who authorized submission of the registration. Form FDA 3733 must be signed and printed or typed with black or dark blue ink. If there is no information available for a specific block in a mandatory section, enter the words “Not Available,” “N/A,” or “None” in that block unless specified otherwise in these instructions. Do not make any entries or marks in the parts of the form designated “FDA USE ONLY.” Some sections of the form contain a check box for making a selection. Check the box when making a selection. All sections on this form are mandatory unless described otherwise. Forms that are incomplete or illegible will not be processed and may considerably delay a requested action (such as issuance of a Shell Egg Producer Registration Number).
Enter the date in the format MM/DD/YYYY. Example: 07/09/2010
Section 1 – TYPE OF REGISTRATION
Subsection 1a. DOMESTIC OR FOREIGN REGISTRATION
Check the box for only one of the two choices. Domestic means that the farm is located in any State or Territory of the U.S., in the District of Columbia, or in the Commonwealth of Puerto Rico. Foreign means all others.
Subsection 1b. INITIAL REGISTRATION
Check the box for Initial Registration only if this is the first time you have registered this farm with FDA under FDA’s final rule, “Prevention of Salmonella Enteritidis in Shell Eggs During Production, Storage, and Transportation.”
Subsection 1b. UPDATE OF REGISTRATION INFORMATION
If you are updating information for an existing Shell Egg Producer Registration, please check this box and provide the current Registration Number in subsection 1c. A form submitting an update will not be processed without the appropriate Registration Number.
Subsection 1b. NOTIFICATION OF CEASING OPERATIONS
If you are ceasing or have ceased operations, check this box and enter the date that you will be ceasing (or have ceased) operations.
Subsection 1c. UPDATE OR CEASING OPERATIONS NOTIFICATION
If this is an update or ceasing operations notification, provide the Shell Egg Producer Registration Number in the blank.
Subsection 1d. UPDATE INFORMATION
Check the box for each update that applies and further identify changes in the applicable section(s). If this is a new registration, leave this section blank.
Subsection 1e. NEW OWNER INFORMATION
If you are a new owner of a previously registered facility, you must re-register. Please provide the previous owner’s name and registration number, if known.
Section 2 – FACILITY NAME/ADDRESS INFORMATION
Provide the requested information in the blocks provided. If the facility name and address are already listed with the FDA for some other purpose, be sure to use the exact same facility name and address for Section 2.
Section 3 – PREFERRED MAILING ADDRESS INFORMATION (OPTIONAL)
If you prefer to be contacted at an address other than that of the facility, please print or type the requested information in the blocks provided in this section of the form.
Section 4 – SEASONAL FACILITY DATES OF OPERATION (OPTIONAL)
If your farm operates only during parts of the year, enter the date ranges when the facility operates. Example: “Open June 1st through August 31st and October 1st through December 20th.”
Section 5 – SIZE OF OPERATION
Fill in the average or usual number of layers in each poultry house on the farm and the total number of poultry houses on the farm.
Section 6 – OWNER OR OPERATOR INFORMATION
If the contact information for the owner OR operator is the same as that in another section of the form, check the box corresponding to that section; otherwise, enter the information as requested. The fax number and e-mail address for the owner or operator are optional.
Section 7 – CERTIFICATION STATEMENT
Either the owner or operator of the facility, or an individual authorized by the owner or operator of the facility, such as an agent in charge, must submit this form. By submitting the form to FDA, or by authorizing an individual to submit the form to FDA, the owner or operator of the facility is certifying that the information contained in the form is true and accurate. If an individual authorized by the owner or operator of the facility submits the form to FDA, that individual also certifies that the information contained in the form 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 of the facility must identify in this section the name and contact information for the individual who authorized submission of the registration. Anyone who makes a materially false, fictitious, or fraudulent statement to the U.S. Government is subject to criminal penalties under 18 U.S.C. 1001.
Signature of Submitter
The submitter is required to sign this form in black or dark blue ink.
Printed Name of Submitter
Print or type the name of the person submitting the registration in this space.
Check One Box
If the submitter is the owner or operator, check box A, “OWNER OR OPERATOR.” If the submitter is an individual authorized by the owner or operator (such as an administrative employee), check box B, “INDIVIDUAL AUTHORIZED TO SUBMIT THE REGISTRATION.”
If you checked box B, check either the box, “ Owner or Operator ,” if the owner or operator authorized you to submit the registration), or the box, “_______ – Name of individual who authorized registration on behalf of the owner or operator ,” if someone other than the owner or operator authorized you to submit the registration. If you checked, “Owner or Operator,” you are finished with the form. If you checked, “________ – Name of individual who authorized registration on behalf of the owner or operator,” complete the name and address information for the individual who authorized you to submit the registration on behalf of the owner or operator. The fax number and e-mail address for that individual are optional.
Do not mail these instructions back to the FDA with your form. Keep them with your records.
Mail completed Form FDA 3733 to U.S. Food and Drug Administration/Food Facility Registration, 5100 Paint Branch Parkway, HFS-681, College Park, MD 20993, or FAX it to (301) 436-2804.