FOOD SAFETY MANAGEMENT SYSTEM CERTIFICATION

QUESTIONNAIRE
This questionnaire is sent to applicants to allow us to understand your business and to provide you with the best possible service. PLEASE COMPLETE IN BLOCK LETTERS. 1. Details of applicant: Name of company & ROB/ROC No. Division (if applicable) Postal Address Contact Position Telephone Telex/Telefax E-mail : : : : : : : : _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ Alternate Contact Position Telephone Telex/Telefax E-mail Yes No : : : : : _________________________ _________________________ _________________________ _________________________ _________________________

Do you trade under any other trading names? If Yes give further details:

Is your organisation part of some larger organisation? If Yes give name of holding company :

Yes

No

Legal status of applicant (eg. registered company, statutory body etc.) : Category of company (more than one may be applicable) - applicable for Malaysian companies only : SMI Large 2. Sites Multinational Joint Venture Origin : Other

Please specify all sites where activities relating to the implementation of the food safety system are carried out. Please include site listed above if it is applicable. a) Address :

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Activities

No. of employees

Details of shift system

b)

Address

Activities

No. of employees

Details of shift system

(If more sites are to be covered, please provide a separate list.) Total number of employees in sites to be certified : Please enclose companys organisation chart.
(Note : Employees above refers to all employees involved in the implementation of the food safety management system for the scope of activities to be certified. Part time and subcontracted employees, if applicable, shall be included)

3. Other Information: (a) Please give details of any system certification (eg ISO 9000, GMP) currently held and the name of the certification : (b) Please specify national/international regulations which your product or service has to comply with:

(c) Please include the details of consultant (name and company) who had assisted you in the development of the system: ________________________________________________________________________

4. Activity For Which Certification Is Sought

4.1 Please describe within the space provided the scope of your organizations activity for which certification is sought.

4.2 Please list products/services to be covered by the certification with details of the processes involved. PLEASE PROVIDE DETAILS OF PRODUCTS TO BE COVERED, THE RAW MATERIALS
USED (BY PRODUCT TYPE) AND THE RELEVANT PROCESS FLOW CHARTS CLEARLY INDICATING THE CCPS.

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5. Equipment Details (for manufacturing companies only): Please indicate principal plant or equipment used (if applicable). PLEASE ENCLOSE PLANT
LAYOUT WITH INDICATION OF MANUFACTURING LINES.

(If space is insufficient, please provide a separate sheet) 6. Other Products or Services: List any other products manufactured or services offered for which certification is not being sought.

7. List major activities which have been sub-contracted (if applicable):

8. Do you have a documented system? Yes No If yes, please specify : __________________________________________________________________ How long has it been implemented? _______________ months If no, when will you begin to document your system?

9. a) Please tick (b) to indicate type(s) of Food Safety Management System certification sought: MS 1480 (HACCP)* ISO 22000 MS 1514 (GMP)

b) *Please tick (b) to indicate the certification scheme sought (please tick one only) :
Ministry of Health Malaysian Certification Scheme for HACCP & SIRIM QAS International Food Safety System Certification Scheme SIRIM QAS International Food Safety System Certification only Ministry of Health Malaysian Certification Scheme for HACCP only

Good Manufacturing Practice

c) We would like to combine Food Safety System Certification with ISO 9001:2000 Certification: Yes No

Note : To assist our staff who may be visiting your organisation, please attach directions to your companys location or attach a map indicating the location and, if parking is a problem, please advise nearest public car parking facility.

Thank you for your co-operation in completing the questionnaire. Please ensure that all information requested have been provided in full to expedite the processing.
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