DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Adnimstration
PRIOR NOTICE SUBMISSION		 Form Aproved: OMB No. 0910-
Expiration Date:

Paperwork Reduction Act Statement

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. Public reporting burden for this collectlon of information is estimated to average 0.5-1.0 hours per response, including time for reviewing instructions, searchmg existing data sources, gathering and maintaining the necessary data, and completing and reweing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to the address to the right:

Food and Drug Administration
Center for Food Safety and Applied Nutrition
Office to be Determined
5100 Paint Branch Parkway College Park, MD 20740-3835

Initial Held Amendment Product Identity Update Arrival Info Cancel

Mandatory Information Mandatory if applicable
 

Submitter
First Name  
Last Name  

Submitting Firm
U.S. Purchaser U.S. Importer
U.S. Agent of Purchaser U.S. Agent of Importer
Carrier In-bond Carrier
Name of Firm  
FDA Registration Number N/A #
Street Address  
City  
State  
Zip  
Phone  
Fax  
E-mail address  

Tipo de Entrada
Consumption T&E IE Mail Trade Fair
Warehouse TIB Baggage Other
   
Entry Type Customs Code
 
Customs Entry Number/Customs Line Number/FDA Line Number
                                 
 
Article held under FDA direction No Yes
Name of Location  
Street Address  
City  
State   Zip  
Contact Name   Phone  

           
Date available at Location mm/dd/yy
 

Product Identity
             
FDA Product Code
Common/usual/market name  
Trade/brand name  
Quantity Number Measure
Identifiers Lot number Production Code
1  
2  
3  
4  

Manufacturer
Name of Firm  
FDA Registration Number N/A #
Street Address  
City  
State/Province  
Country  
Zip/Mail code  
Phone  
FAX  
E-mail address  

Grower
Name of Firm  
Street Address  
City  
State/Province  
Country  
Zip/Mail code  
Phone  
FAX  
E-mail address  
Growing Location street  
Growing Location City  
Growing Location State/Province  

Growing Location Country

  
Growing Location Zip/Mail code  

ADDITIONAL GROWERS No Yes How Many?  

GROWER 2
Name of Firm  
Street Address  
City  
State/Province  
Country  
Zip/Mail code  
Phone  
FAX  
E-mail address  
Growing Location street  
Growing Location City  
Growing Location State/Province  
Growing Location Country  
Growing Location Zip/Mail code  

GROWER 3
Name of Firm  
Street Address  
City  
State/Province  
Country  
Zip/Mail code  
Phone  
FAX  
E-mail address  
Growing Location street  
Growing Location city  
Growing Location State/Province  
Growing Location Country  
Growing Location Zip/Mail code  

Originating Country

 IS0 code
   

Shipper
Name of Firm  
FDA Registration Number S/N #
Street Address  
City  
State/Province  
Country  
Zip/Mail code  
Phone  
FAX  
E-mail address  

Country from which the article was shipped IS0 code
   

Anticipated Arrival Information
Name of Crossing  
City of Crossing  
State of Crossing   Port of Entry Code
       
Anticipated Date of Crossing mm/dd/yy
           
Anticipated Time of Crossing
       
am pm
 
Port of Entry for Customs Purposes (port code)
       
Date of Entry for Customs Purposes mm/dd/aa
           

Importer
Name of Firm  
FDA Registration Number N/A #
Street Address  
City  
State  
Country  
Zip  
Phone  
FAX  
E-mail address  

Owner
Name of Firm  
FDA Registration Number N/A #
Street Address  
City  
State  
País  
Zip  
Phone  
FAX  
E-mail address  

Consignee
Name of Firm  
FDA Registration Number N/A #
Street Address  
City  
State  
Country  
Zip  
Phone  
FAX  
E-mail address  

Carrier 1
Standard Carrier Abbreviation Code
       
Name of Firm  
Street Address  
City  
State/Province  
Zip/mail code  
Country  
Phone  
FAX  
E-mail address  
Additional Carriers No Yes How Many?
 

Carrier 2
Standard Carrier Abbreviation Code
       
Name of Firm  
Street Address  
City  
State/Province  
Código Postal  
ZIP Mail code  
Phone  
FAX  
E-mail address  

Carrier 3
Standard Carrier Abbreviation Code
       
Name of Firm  
Street Address  
Citv  
State/Province  
Country  
Zip/Mail code  
Phone  
FAX  
E-mail address  
 
Amendment to follow Yes No
 
Cancel this submission Si No
 
This form must be submitted by the U.S. Importer or U.S. Purchaser, or U.S. Agent of the importer or purchaser, of the article of food being imported or offered for import. 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.

FORM FDA 3540 (01/03)


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