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Initial

Re-Audit

Annual Renewal

Application for Wal-Mart Facility Security Assessment

Section 1: Invoiced Details

Company Name
(English & Local Language)

Address
(English & Local Language)

Contact Name Telephone Number Fax Number (For billing) E-mail Address

Section 2: Details of Wal-Mart Supplier

Name of Wal-Mart Supplier Address


(English & Local Language)

Contact Name Telephone Number E-mail Address Wal-Mart Supplier ID Name of Port Name of Carrier

Section 3: Details of Physical Facility to be visited


Form No.: WM Application Issue No.: 00 Issue Date: 14 Mar 2011 Page 1 of 3

Intertek Testing Services Bangladesh Ltd. Should you have any query, please feel free to contact Abdullah Al Muktadir at Direct line: 8961184/ Fax: 912 5866 / Email: abdullah.muktadir@intertek.com

Name of Physical Facility


(English & Local Language)

Address
(English & Local Language)

Contact Name Telephone Number Fax Number E-mail Address Wal-Mart Facility ID Number

Wal-Mart GP Department No.


Remark: The facility name and address filled above would be adopted directly for Certificate issuing without further confirmation.

Section 4: Basic Information Industry Type

Agriculture Footwear Electronic Food Apparel

Computer Chemical Toys and Hardlines Cosmetics Other:

Main Product Number of Employees Language of Employees Number of Buildings Distribution Center Production Warehouse Container Yards Other Yes Are warehouse(s) customs bonded? Are facilities located in a Free-Trade Zone? High Value Parts? Hazardous Materials? Perishables?
Form No.: WM Application Issue No.: 00 Issue Date: 14 Mar 2011 Page 2 of 3

No

Intertek Testing Services Bangladesh Ltd. Should you have any query, please feel free to contact Abdullah Al Muktadir at Direct line: 8961184/ Fax: 912 5866 / Email: abdullah.muktadir@intertek.com

Chemicals? Munitions / Dual Use? Audit Date Required

Section 5: Fee for WM SECURITY Audit

Manday Charge*:

USD500.00 (*Out of Pocket Expense is inclusive)

Special Note:
a. It is usually needed three weeks to arrange the inspection. Intertek will do all the best to make arrangement to meet your expectation. We will inform you via email to propose a new audit date if it is different from the requested date you specified. Under this situation, audit will be conducted after your email endorsement. b. Normally, the audit can be completed within a day if the number of employee of facility is not more than 4000. c. If formal notice of cancellation or rescheduling of an on-site audit is provided by Applicant, the fee charges will be according to below: Days prior to the committed audit date 2 5 working days (both days included) Less than 2 working days Access Denied Audit fee 50% of quoted charge Full quoted Charge Full Charge

d. Intertek is authorized to send report copy to Wal-Mart or its designated associates directly. e. Audit final result would be decided by Wal-Mart. f. Our service is subject to our Terms & Conditions of Business. Details are separately attached.

Section 6: Application Form Completed by and Terms agreed by

Name and Position Authorized Signature

Date

Form No.: WM Application Issue No.: 00

Issue Date: 14 Mar 2011 Page 3 of 3

Intertek Testing Services Bangladesh Ltd. Should you have any query, please feel free to contact Abdullah Al Muktadir at Direct line: 8961184/ Fax: 912 5866 / Email: abdullah.muktadir@intertek.com