Fsis Form 7234 1 – Fill Out and Use This PDF

FSIS FORM 7234-1 (11/16/2011) page 4

PAGE

of

A.

PREPARATION OF APPLICATION

7b.

Total available labeling space in square inches for entire package.

Application must be typed or it will be returned without evaluation.

8.

USDA-AMS Child Nutrition Program Logo. Indicate if the product

Submit two copies for each label application.

includes a USDA-AMS Child Nutrition Program Logo.

B.

TYPE OF APPROVAL REQUESTED

9.

Leave Blank. For USDA-AMS use only.

Sketch: Self explanatory. (See 9 CFR 317.4 & 381.132)

Temporary and Extension of Temporary. Actual label or color litho take off to be used.

10.

Special claims, guarantees, or foreign language. Indicate if there are

are any special claims, guarantees, or foreign language on the label.

C.

FOREIGN LANGUAGE

Check all that apply. If Other Claims is selected, indicate specific claim(s)

Labels printed in foreign languages must be accompanied by English language translation.

in space provided.

D.

ASSEMBLY OF APPLICATION

11.

Name and Address of Firm. Insert Firm's name and mailing

Application Form, Product Formula, Processing Procedures, Continuation Sheet if applicable, Label,

address. Use 2 letter symbol for State. Show postal zip code.

and any Supporting Documentation Staple with one or as few staples as possible. (Do not use paper

12 & 13.

Signature and Date of Applicant or Agent. To be signed and

clips).

dated by the applicant or agent representing the official

E.

MAIL COMPLETED APPLICATION TO:

establishment or plant.

USDA, FSIS, OPPD, LPDD

14.

Labeling Distribution Unit

Leave blank for USDA use only. Conditions Applying to Use of Label or

Stop Code 3786, Patriots Plaza III, 8-168

Device. (Any condition, modification or remarks applied to the application

1400 Independence Avenue, SW

when approved are conditions governing use of the approved devices.)

Washington, DC 20250-3700

The following instructions relate to numbered items on form.

15.

Product Formula. List the ingredients by percent or weight in order of

1.

If using an Agent, provide the company name, address, and telephone number,

their predominance. If product consists of several components, e.g.,

a frozen dinner, list each component separately and indicate the

otherwise leave blank.

percentage or amount of each component in the product. If additional

2 & 3.

Leave blank, for USDA use only.

space is needed, check the box for "Continuation Sheet," and use the

Continuation Sheet. Be sure to include the product name and number

of the block item. Express all ingredients in the same units, i.e., do not

4.

Establishment No./Foreign Country (if applicable) - Self Explanatory.

list some in pounds and others in ounces.

4a.

Type of Product. Select one product type: Egg, Meat, Poultry, or Other (i.e. Exotic Species,

Non-Amenable, Voluntary, etc.)

Check whether weight or percent is used. It is preferred that

5a.

Name of Product. Use common or descriptive product name, i.e., "Frankfurter ,

percentages be used, and the total must equal 100 percent. If weights

are used, show in pounds, kilograms or grams. (No gallons, pints,

Cereal Added" or "Meat Patties in Gravy. (Do not use trade brand names or

cups, teaspoons, etc.) The total must equal the weights of the

coined names, such as "Joe's Corn Dogs" or "Joe's Sloppy Joes.") If coined

individual units. (Example: Crust + Cheese + Sauce + Meat = Total

names such as "Corn Dogs" are used, also show true product name, such as

new weight of unit.)

"Batter Wrapped Wiener."

5b.

Provide HACCP process category for the product. See 9 CFR 417.2(b) (1),

DO NOT use fractions. Express as decimals carried to two places, Example:

Example, Heat Treated - shelf stable, Not heat treated-shelf stable etc. Select one.

1-1/4 lbs., show as 1.25 lbs. Example: 3/4 lbs., show as .75 lbs.

6a & b.

Type of Approval Requested. If temporary approval or extension, insert

number of days requested and number of labels on hand. If previous

approval, attach copy of application and label. Include specific reason(s)

16.

Processing Procedures. Poultry Products provide complete

why requesting a temporary or extension and include information required

in 9 CFR 317.4(f) (1) or 381.132(f) (1) on the continuation sheet.

processing procedures as required in 9 CFR 381.134. Meat

Be sure to include product name and block item.

Products, provide complete processing procedures as required.

Note: Approval of the sketch does not convey approval of the

7a.

Area of Principal Display Panel (PDP). The PDP is the entire side

processing procedures. If additional space is needed, check the box for

"Continuation Sheet," and use the Continuation Sheet.

of the package to which the label is affixed. See 9 CFR 317.2 (d)

Be sure to include the product name and number of the block item.

and 381.116 (b).

FSIS FORM 7234-1 (11/16/2011)