Form FDA 3038 FDA 3038 Interstate Shellfish Dealers Certification

(Check One)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

Certification

Change

(See Reverse of Part III for Instructions)

Cancellation

Renewal

Form Approved: OMB No. 0910-0021
Expiration Date: xxxxxx xx, 20xx
See Burden Statement on back of Part III.

SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY
2.

1. SHELLFISH DEALER / SHIPPER (Name)

CERTIFICATION

a) CERTIFICATE NUMBER

b) DATE CERTIFIED

c) STATE

d) EXPIRATION DATE

FACILITY ADDRESS (Include Street No., City, State, & ZIP)

MAILING ADDRESS (If different than above)

e) CATEGORY SYMBOL

TELEPHONE

(

)

DP - Depuration

RP - Repacker

RS - Reshipper

SP - Shucker-Packer

SS - Shell Stock Shipper

PHP - Post Harvest
Processor

3. DATE OF ON-SITE INSPECTION

4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print
Name)

6. CANCELLATION DATE

7. REASON FOR CANCELLATION (Check One)
Decertification

5. EXPIRATION DATE OF INSPECTOR’S
STANDARDIZATION

Out of Business

Other (Please Specify)
8. a) STATE SHELLFISH CONTROL AUTHORITY
DESIGNEE (Print Name)

b) SIGNATURE

c) DATE CERTIFICATE SENT TO FDA

SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED

10. DATE CERTIFICATE PUBLISHED

THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (10/06)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)

PART 1 - HFS-625

INTERSTATE SHELLFISH
DEALER’S CERTIFICATE
PSC Graphics: (301) 443-1090

EF

(Check One)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

Certification

Change

(See Reverse of Part III for Instructions)

Cancellation

Renewal

Form Approved: OMB No. 0910-0021
Expiration Date: xxxxxx xx, 20xx
See Burden Statement on back of Part III.

SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY
2.

1. SHELLFISH DEALER / SHIPPER (Name)

CERTIFICATION

a) CERTIFICATE NUMBER

b) DATE CERTIFIED

c) STATE

d) EXPIRATION DATE

FACILITY ADDRESS (Include Street No., City, State, & ZIP)

MAILING ADDRESS (If different than above)

e) CATEGORY SYMBOL

TELEPHONE

(

)

DP - Depuration

RP - Repacker

RS - Reshipper

SP - Shucker-Packer

SS - Shell Stock Shipper

PHP - Post Harvest
Processor

3. DATE OF ON-SITE INSPECTION

4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print
Name)

6. CANCELLATION DATE

7. REASON FOR CANCELLATION (Check One)
Decertification

5. EXPIRATION DATE OF INSPECTOR’S
STANDARDIZATION

Out of Business

Other (Please Specify)
8. a) STATE SHELLFISH CONTROL AUTHORITY
DESIGNEE (Print Name)

b) SIGNATURE

c) DATE CERTIFICATE SENT TO FDA

SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED

10. DATE CERTIFICATE PUBLISHED

THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (10/06)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)

PART 2 - REGIONAL SHELLFISH SPECIALIST

INTERSTATE SHELLFISH
DEALER’S CERTIFICATE

(Check One)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

Certification

Change

(See Reverse of Part III for Instructions)

Cancellation

Renewal

Form Approved: OMB No. 0910-0021
Expiration Date: xxxxxx xx, 20xx
See Burden Statement on back of Part III.

SECTION I - COMPLETED BY STATE SHELLFISH CONTROL AUTHORITY
2.

1. SHELLFISH DEALER / SHIPPER (Name)

CERTIFICATION

a) CERTIFICATE NUMBER

b) DATE CERTIFIED

c) STATE

d) EXPIRATION DATE

FACILITY ADDRESS (Include Street No., City, State, & ZIP)

MAILING ADDRESS (If different than above)

e) CATEGORY SYMBOL

TELEPHONE

(

)

DP - Depuration

RP - Repacker

RS - Reshipper

SP - Shucker-Packer

SS - Shell Stock Shipper

PHP - Post Harvest
Processor

3. DATE OF ON-SITE INSPECTION

4. STATE SHELLFISH STANDARDIZATION INSPECTOR (Print
Name)

6. CANCELLATION DATE

7. REASON FOR CANCELLATION (Check One)

5. EXPIRATION DATE OF INSPECTOR’S
STANDARDIZATION

Decertification

Out of Business

Other (Please Specify)
8. a) STATE SHELLFISH CONTROL AUTHORITY
DESIGNEE (Print Name)

b) SIGNATURE

c) DATE CERTIFICATE SENT TO FDA

SECTION II - COMPLETED BY DIVISION OF COOPERATIVE PROGRAMS - FDA
9. DATE CERTIFICATE RECEIVED

10. DATE CERTIFICATE PUBLISHED

THIS CERTIFICATE MUST BE KEPT ON FILE FOR A PERIOD OF TWO (2) YEARS.
FORM FDA 3038 (10/06)
(Replaces Forms FDA 3038b and FDA 3038c which are obsolete.)

PART 3 - STATE REGULATORY AGENCY

INTERSTATE SHELLFISH
DEALER’S CERTIFICATE

Instructions for completing Form FDA 3038 (10/06)
Section I - Completed by State Shellfish Certification Agency
1. Shellfish Dealer/Shipper: Name, Facility Address, Street
No., City/Town, State, ZIP, and Telephone. Include mailing
address if different than physical location of facility.
2. Certification: Certificate Number - a unique number assigned to each certified shellfish dealer; Date Certified;
State - two letter State Code; Expiration Date - date
certificate expires; Category Symbol - two or three letter
code designating dealer process.
3. Date of On-Site Inspection: Date plant was inspected for
certification.

6. Cancellation Date: Date firm has been either decertified or
recommended for delisting.
7. Reason for Cancellation: Check applicable box. Other
denotes voluntary or seasonal suspension of activities.
8.a) State Shellfish Control Authority designee: Print name to
validate signature block.
8.b) Signature of designee
8.c) Date certificate sent to FDA

4. State Shellfish Standardization Inspector: Print name of
Inspector who conducted the on-site inspection.
5. Expiration Date of Inspector’s Standardization: Print date
the inspector’s standardization will expire.

Section II - Completed by Division of Cooperative Programs - FDA
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