FSIS FORM 5200-2, APPLICATION FOR FEDERAL INSPECTION 

 (Meat, Poultry, Siluriformes Fish, Egg Products, and Import)
 Page 1 

 

 1. Date of Application: Put current date application is completed. 

 1a. Existing Establishment Number, if applicable. 

 2. Type of Application (check all that apply). 

 3. Type of Inspection (check all that apply). 

 4. Form of Organization (check applicable box). 

 5. If Corporation, Name of State where Incorporated. 

 6. Date Incorporated: Show month, date, and year, e.g., mm/dd/yyyy. 

 7. Name and Address of Corporate Headquarters. 

 8. Federal Employer ID #. 

 9. Dun & Bradstreet #, if applicable. 

 10. Firm's Code (Import Only). 

 11. Name of Applicant (person, firm, or corporation making application) and mailing address. 

 12. Telephone number and e-mail address of applicant. 

 13. Actual Name of Company and Physical Location Address of Establishment. 

 14. Telephone number and e-mail address of establishment.

 15. Establishment Limits: Provide a diagram, schematic or written narrative of the establishment premises that is requested to be under Federal inspection. 

 16. Name and establishment number of other official establishments located in the same facility, if applicable. 

 17. Other names - Doing Business As (DBA). Use continuation sheet if necessary. 

 18. Month and year when establishment will be ready to operate under inspection. 

 SECTION II. ESTABLISHMENT INFORMATION - (Page Three)

SECTION I. APPLICANT INFORMATION - (Page Three)

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT - (Pages Five and Six) 

 22. The applicant must provide a list of persons responsibly connected with the establishment Include all partners, officers, directors, holders, or owners if 10% or more of its 

 voting stock or employees in a managerial or executive capacity. Check the appropriate box for 10% or more voting stock. Use continuation sheet or provide an attachment, 

 if necessary. 

 23. Self-explanatory. If none, check the None box. If yes, check the Yes box and explain. 

 24. Self-explanatory. If none, check the None box. If yes, check the Yes box and explain. 

 25. Have conditions for receiving inspection been met (SSOP, Recall Procedures, HACCP) in accordance with 9 CFR 304.3 and 381.22? Check all applicable boxes. 

 26. Privacy Act Notice. Check appropriate box.

PLEASE READ AGREEMENT, CERTIFICATION, AND WARNING STATEMENT

 27. Typed or written name and title of person signing application. (Must be listed in Block 22). 

 28. Signature: By signing your name in this block you are stating that the information provided is accurate and binding. 

BLOCKS 29, 30, 31, 32, AND 33 - TO BE COMPLETED BY USDA, FSIS, OFO DISTRICT OFFICE ONLY

19A.

19B.

21B.

19D.

19C.

20.

21A.

21C. and 21D. Check all applicable boxes Types of Products (IMPORT INSPECTION ONLY)

INSTRUCTIONS FOR COMPLETION OF FSIS FORM 5200-2

Complete all sections. Enter N/A if a section is not applicable. Use continuation sheet if needed on Page 7 and number the item. To submit electronically, 

access the FSIS Form 5200-2, Application for Federal Inspection, on the https://www.fsis.usda.gov/employees/hr-policies-systems/forms page. Complete the 

electronically-fillable form and save the form on your hard drive. Print the form and sign it. Scan the form and e-mail the completed form to the Grant Curator in 

the appropriate District Office. For paper copies, send the signed application form to the Grant Curator at the District Office mailing address. 

SECTION Ill. TYPE OF OPERATIONS - Meat, Poultry, Siluriformes Fish, Egg Products, and Import Inspection - (Page Four)

 Check all applicable boxes for the types of products intended for processing operations at the establishment. 

 Check all applicable boxes to indicate the type of exempt activities and provide an attachment to explain how the activities will be separated by time or by space. 

 Check all applicable boxes under JURISDICTION 

 Check all applicable boxes (EGG PRODUCTS INSPECTION ONLY) 

 Check all applicable boxes for Species (IMPORT INSPECTION ONLY) 

 Check all applicable boxes for Mode of Transportation (IMPORT INSPECTION ONLY)

 For slaughter operations, check all applicable boxes of animals to be slaughtered at the establishment. For cell-cultured operations, check all applicable boxes 

 of animal cells to be harvested at the establishment.
 Page 2

UNITED STATES DEPARTMENT OF AGRICULTURE (USDA) 

FOOD SAFETY AND INSPECTION SERVICE (FSIS) 

OFFICE OF FIELD OPERATIONS (OFO)

PRIVACY ACT NOTICE 

 

 

AUTHORITY FOR REQUESTING INFORMATION 

 

Authority for requesting both personal and business information is contained in the Federal Meat Inspection Act 

(21 U.S.C.601 et seq.) and the Poultry Products Inspection Act (21 U.S.C. 451 et seq.). Under these Acts, the 

Secretary of Agriculture is authorized to determine the fitness of applicants for or recipients of inspection service 

to engage in business requiring inspection. Your disclosure of personal information to aid in this determination is 

mandatory. The Acts also require full and complete disclosure of records and information showing the 

transactions of your business. 

 

PURPOSE FOR WHICH THE INFORMATION WILL BE USED 

 

This information is being requested to establish and record your identity as a responsible official of the business 

and to determine your fitness to receive a Grant of Inspection. 

 

ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION 

 

In appropriate situations, a report containing the information you furnish may be referred to other federal, state, 

local or foreign agencies charged with law enforcement or the investigation or prosecution of law violations. 

 

EFFECTS OF FAILURE TO FURNISH INFORMATION 

 

Failure to provide requested information may delay or interfere with your receiving inspection service and may 

result in civil penalties of $100.00 per day against you or your business, as prescribed by (15 U.S.C. 50). In 

addition, persons making false, fictitious, or fraudulent statements or entries are subject to a $10,000.00 fine or 

imprisonment for not more than 5 years or both, as prescribed by (18 U.S.C 1001). 

This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, religion, sex, national origin, 

age or disability, immediately contact USDA, Office of the Assistant Secretary for Civil Rights, 1400 Independence Ave., S.W., Stop 

9410, Washington, DC 20250-9410, Toll-Free: (866) 632-9992, Federal relay: (800) 877-8339, Spanish relay: (800) 845-6136, Fax: (202) 

690-7442, Email: Program.intake@usda.gov

The Privacy Act of 1974 (5 U.S.C. 522A) requires that certain information be given to you when you are 

requested to furnish personal information to a Government Agency. The required information is provided in this 

Notice. The act does not apply, however, to business information about your firm. 
 

 

 APPLICATION FOR FEDERAL INSPECTION 

 (Meat, Poultry, Siluriformes Fish, Egg Products and Import Inspection)

SECTION I. APPLICANT INFORMATION

 1. Date of Application

New

3. Type of Inspection (check all that apply) 

Individual

Meat 

4. Form of Organization (check applicable box)

5. If Corporation, Name of State or 

Territory where Incorporated

8 Federal Employer ID#

10. Firm's Code (Import Only) 

 Change of Location 

 Cooperative 

 Association Partnership

Poultry

Change of Ownership

Corporation Education Institution Limited Liability 

Company (LLC) Other 

Egg Products Import Siluriformes Fish

11. Name of Applicant (person, firm or corporation making application) and mailing 

address 

Name

Address

City

Zip 

Code State

12. Telephone number and e-mail address of applicant

13. Actual Name of Company and Physical Location Address of Establishment

on continuation sheet attached document previously submitted

6. Date Incorporated 

9. Dun & Bradstreet # (if applicable)

 e-mail 

phone

7. Name and Address of Corporate Headquarters

16. Name and establishment number of other official establishments located in the 

same facility (if applicable) 

SECTION II. ESTABLISHMENT INFORMATION

17. Other names - Doing Business As (DBA) - Use continuation sheet 

 if necessary

Submit this application electronically, or by mail, to the Grant Curator at the appropriate 

U.S. Department of Agriculture, Food Safety and Inspection Service, District Office. 

Complete all sections. If a section is not applicable, enter N/A or None. If additional 

space is needed for any items, use the continuation sheet provided or an attachment. 

Number the item. 

Other, specify:

 mm/ dd/ yyyy

15. Establishment Limits: Provide a diagram, schematic or written narrative of the establishment premises that is requested to be under Federal inspection. Use 

continuation sheet or attachment if necessary. 

by other means (mail, courier)

18. Estimated date when the establishment will be ready to operate under 

inspection (mm/ dd/ yyyy)

Name

Address

City

Name

Address

City

 Zip 

Code State

1a. Existing Establishment Number (if applicable)

U.S. DEPARTMENT OF AGRICULTURE 

FOOD SAFETY AND INSPECTION SERVICE

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The 

valid OMB control number for this information collection is 0583-0153. The time required to complete this information collection is estimated to average 10 minutes 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.

Country

Country

Zip 

Code State Country

Page 3

2. Type of Application (check all that apply)

14. Telephone number, mailing address and e-mail address of establishment

phone

e-mail 

mailing 

address

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete

Cell-Cultured
Calf

Cattle

Equine

Goat

Swine

Duck

Guinea

Squab

Turkey

Goose

Chicken

Sheep

19A. SLAUGHTER OR 

 HARVEST OPERATIONS

 Raw - Non Intact Products

 Raw - Intact Products

 Thermally Processed 

 Commercially Sterile

 Not Heat Treated - Shelf Stable

 Heat Treated - Shelf Stable

 Fully Cooked - Not Shelf Stable

 Heat Treated Not Fully Cooked - 

 Not Shelf Stable

 Product with Secondary 

 Inhibitors - Not Shelf Stable 

a.

b.

c. 

d.

e.

f.

g.

h.

 19B. PROCESSING 

 OPERATIONS 

Custom Processing

Custom Slaughter

Retail Activities

Buddhist eviscerated Poultry 

Confucian Non-eviscerated 

Poultry

Islamic (Halal) Poultry

Halal

Kosher

Religious Exempt Livestock

Religious Exempt Poultry

FSIS Inspection only

 19C. EXEMPTIONS (explain separation 

 from inspected products on continuation 

 sheet)

 19D. JURISDICTION (explain 

 separation from inspected 

 products on continuation sheet) 

State Inspection 

Talmadge-Aiken

Multiple Agencies

Dual Jurisdiction 

Establishment with Food 

and Drug Administration 

(FDA)

USDA Agricultural 

Marketing Service 

(AMS) Grading/Quality 

Control

Establishment provides 

products for the National 

School Lunch Program

20. EGG PRODUCTS INSPECTION (check all that apply)

a. Fully Cooked - Not Shelf Stable c. Raw - Non-Intact

Poultry

Egg Products

Siluriformes Fish

Meat 

21A. Species 21C. Types of Products 

 (egg products)

 21D. Types of Products (meat and poultry only)

Liquid Eggs

Frozen Eggs

Dried Eggs

21B. Mode of Transportation

Rail Cars

Trucks

Ocean Vessel

Airline

Fully Cooked - Not Shelf Stable

 Frozen

 Heat Treated - Shelf Stable 

Not Heat Treated - Shelf Stable 

Perishable

Raw - Intact 

Product with Secondary Inhibitors - 

Not Shelf Stable

 Raw - Non-Intact 

Ground product

Other Non-intact

Cuts (including bone-in 

and boneless meats)

Boneless and/or skinless parts

Other Intact 

Carcasses

Beef

Goat

Mutton

Thermally Processed/Commercially 

Sterile

Poultry

Equine

Lamb

Pork

Ratite

Veal Veal-hide on

Soups

Other Ham

Corned (species)

Heat Treated - Not Fully Cooked - 

Not Shelf Stable 

N/A

19. MEAT, POULTRY, AND SILURIFORMES FISH INSPECTION ACTIVITIES (check all that apply)

Kosher Non-eviscerated Poultry

21. IMPORT INSPECTION (check all that apply)

 Frozen from an APHIS restricted 

 country 9 CFR 94.4 (b)

Other (specify on continuation 

sheet)

Ratite

Other, 

specify: 

SECTION III. TYPE OF OPERATIONS Page 4

Siluriformes Fish

d. Egg Breaking

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete

b. Heat Treated - Shelf Stable
22. The applicant must provide a list of persons responsibly connected with the establishment. Include all partners, officers, directors, holders, or owners of 10 percent or 

more of voting stock or employees in a managerial or executive capacity. Check the appropriate box for 10% or more voting stock. Use continuation sheet or provide an 

attachment if necessary. 

Last Address

City

Country

First e-mail 

Title

Name and Title Present e- mail and home address

Last Address

 e-mail 

First

Title

yes

no

Last Address

 e-mail First

Title

yes

no

Last Address

 e-mail First

Title

yes

no

Last Address

 e-mail First

Title

yes

no

Last Address

First e-mail 

Title

Holder of 10% or more voting 

stock? (if corporation)

SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT Page 5

 State Zip 

 Code

City

Country State Zip 

 Code

City

Country State Zip 

 Code

City

Country State Zip 

 Code

City

Country State Zip 

 Code

City

Country State Zip 

 Code

yes

no

yes

no

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete
SECTION IV. PERSONS RESPONSIBLY CONNECTED WITH APPLICANT (continued)

23. Enter the name of each person listed in Block 22 who has been convicted in any Federal or state court of (1) any felony, or (2) more than one violation of any 

law, other than a felony, based upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or fraud in connection with 

transactions in food. Include the nature of the crime(s), indicate felony/misdemeanor, the date of the conviction and the court in which convicted. If none, check 

the box. If yes, check the yes box and explain. Use continuation sheet if necessary.

 Page 6

24. List each conviction against the applicant or recipient (person, firm or corporation) in any Federal or state court of any (1) felony, or (2) more than one 

violation of any law, other than a felony, based upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or 

upon fraud in connection with transactions in food. Include the nature of the crime(s), indicate felony/misdemeanor, the date of conviction and the court in which 

convicted. If none, check the box. If yes, check the yes box and explain. Use continuation sheet if necessary.

27. Typed or written 

name and title of person 

signing application

29. Is this establishment: 

(check all that apply) under State Inspection?

in the Cooperative Interstate 

Shipment (CIS) Program? to be under the TalmadgeAiken Act?

30. Date application 

received by District Office

 31. Official inspection number(s) 

 assigned by District Office 

32. Signature of the 

 District Manager

 33. Date

None Yes, explain

Developed written Sanitation Standard 

Operating Procedures (SSOP)

Conducted a hazard analysis and developed a 

Hazard Analysis and Critical Control Point 

(HACCP) plan 

AGREEMENT AND CERTIFICATION: If inspection is granted under the application, I (we) expressly agree to conform strictly to the Federal Meat Inspection Act 

(21 U.S.C. 601 et seq.), or the Poultry Products Inspection Act (21 U.S.C. 451 et. seq.), or the Egg Products Inspection Act, (21 U.S.C. 1031 et. seq.), and the 

regulations governing the inspection of the meat, poultry or egg product inspection of the United States Department of Agriculture (9 CFR Part 301 et. seq.). I 

CERTIFY that all statements made herein are true to the best of my knowledge and belief. 

WARNING: Persons knowingly and willfully making false, fictitious, or fraudulent statements or entries are subject to $10,000 fine or imprisoned not more than 

five years, or both, as prescribed by Title 18 U.S.C. 1001. This is an Equal Opportunity Program. If you believe you have been discriminated against because of 

race, color, religion, sex, national origin, age or handicap, write immediately to the Secretary of Agriculture or the Administrator, FSIS, Washington, DC 20250.

26. Applicant has been provided with a copy of the Privacy Act Notice?

 Yes No

 28. Signature

Developed written recall procedures

TO BE COMPLETED BY USDA FSIS OFO DISTRICT OFFICE ONLY

None Yes, explain

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete

25. Check appropriate boxes if conditions for receiving inspection have been met in accordance with 9 CFR 304.3, 381.22, and 590.149 for meat, poultry, and 

egg products inspection only. Check all applicable boxes. 

(Does not apply to egg product inspection.)
 Continuation Sheet for FSIS FORM 5200-2 Page 7

FSIS FORM 5200-2 (01/18/2023) Previous Editions are Obsolete