Application for FSIS Accredited Laboratory Program

 PHONE NUMBER: EMAIL ADDRESS: 

 CITY:

US Department of Agriculture 

Food Safety Inspection Service 

Office of Public Health Science 

Accredited Laboratory Program 

Athens, GA 30605

NAME OF PRIMARY CONTACT:

 STATE: ZIP CODE:

2. IF YOUR LABORATORY IS CURRENTLY ACCREDITED BY THE FSIS ALP, PLEASE PROVIDE YOUR ALP LABORATORY NUMBER BELOW:

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 0583-0158. The time required to complete this information collection is estimated to average 

30 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 information.

LABORATORY NAME:

3. HAS YOUR LABORATORY EVER BEEN PEVIOUSLY ACCREDITED BY THE ALP UNDER 

 THE PRESENT OR DIFFERENT NAME? (If no, proceed to section 5)

 3a. If you answered yes in section 3, please provide the ALP laboratory number and the type of accredited measurand:

 1. ACCREDITATION REQUESTED:

Page 1 of 3

ALP #

NAME OF OWNER/MANAGER:

4. WAS YOUR FSIS ALP ACCREDITATION EVER PLACED ON SUSPENSION AND/OR REVOKED?

 TITLE OF PRIMARY CONTACT:

 TITLE OF OWNER/MANAGER:

Chlorinated Pesticides

Polychlorinated Biphenyls (PCB) 

4a. If you answered yes in section 4, please provide the most recent suspension/revocation date: DATE

STREET ADDRESS (PO Box alone not acceptable):

 Yes No

Yes No

Yes No

Please contact the ALP at ALP@usda.gov for available accreditation(s).

Specify Accreditation(s):

MEASURAND

FSIS FORM 10,110-2 (08/25/2022) 

5. IS YOUR LABORATORY CURRENTLY ACCREDITED BY ANY OTHER STATE OR FEDERAL 

 PROGRAM?

Yes No

 LABORATORY NUMBER:

Please contact the ALP at ALP@usda.gov for available accreditation(s).

Specify Accreditation(s):

A. FOOD CHEMISTRY (Moisture, Protein, Fat, and Salt)

B. RESIDUE CHEMISTRY

C. MICROBIOLOGY 

Laboratories are required to have the proper APHIS permits to participate in ALP Microbiology accreditations. 
6. LABORATORY SUPERVISOR HAS A BACHELOR’S DEGREE OR HIGHER IN: 

 (Please enclose transcript or proof of degree. Proof is subject to verification with the degree granting institution). Check All That Apply:

Years 

Experience

Application for FSIS Accredited Laboratory Program

5a. If you answered yes in section 5, please provide the name and description of the programs

a. NAME: 

b. DESCRIPTION: 

7. HAS THE LABORATORY OR ANY INDIVIDUAL OR ENTITY RESPONSIBLY CONNECTED WITH THE 

 LABORATORY BEEN INDICTED OR HAVE CHARGES BEEN BROUGHT AGAINST THE LABORATORY OR 

 RESPONSIBLY CONNECTED INIDIVIDUAL OR ENTITY, IN A FEDERAL OR STATE COURT, CONCERNING ANY 

 OF THE FOLLOWING VIOLATIONS OF LAW?

C. Any misdemeanor based on false statement to any government agency. 

D. Any misdemeanor based upon the offering, giving, or receiving of bribe or unlawful gratuity.

A. Any felony

B. Any misdemeanor based upon acquiring, handling, or distributing of unwholesome, 

 misbranded, or deceptively packaged food or upon fraud in connection with transactions in food.

I certify that, to the best of my knowledge and belief, all information contained herein is true and understand that any willful falsification of this certification is a felony and may result in a 

fine of $250,000 or more for an individual or $500,000 or more for a corporation and imprisonment for not more than 5 years or both (18 USC 1001, 3571, and 3623). I have read the 

rules and requirements contained in 9 CFR Parts 391 and 439 and agree to abide by these rules and other requirements of the FSIS Accredited Laboratory Program.

Food Science 

Food Technology 

Chemistry 

FSIS FORM 10,110-2 (08/25/2022) 

SIGNATURE: DATE:

Yes No

Biology 

Microbiology

Please submit the completed form to: ALP@usda.gov. 

Page 2 of 3

Related Field (specify):
On site review required?

Second Analysis: 

First Analysis:

TO BE COMPLETED BY ACCREDITED LABORATORY PROGRAM OFFICIALS

 Approved Denied (attach reason for denial)

NAME OF REVIEWING OFFICIAL:

LABORATORY NUMBER:

ACCREDITATION QUALIFICATION SAMPLES

OTHER SUPPORTING DOCUMENTATION NEEDED FOR REVIEW:

Fees paid?

Page 3 of 3

 DATE:

Yes No

 Pass Fail

Yes No

FSIS FORM 10,110-2 (08/25/2022) 

Third Analysis: 

SIGNATURE: