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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 : ___________________________ Alternate Contact : _________________________
Position : ___________________________ Position : _________________________
Telephone : ___________________________ Telephone : _________________________
Telex/Telefax : ___________________________ Telex/Telefax : _________________________
E-mail : ___________________________ E-mail : _________________________

Do you trade under any other trading names? Yes No

If ‘Yes’ give further details:

Is your organisation part of some larger organisation? Yes No

If ‘Yes’ give name of holding company :


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 Multinational Origin :

Large Joint Venture Other

2. Sites
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 company’s 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 organization’s 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 SIRIM QAS International Ministry of Health
Certification Scheme for Food Safety System Certification Malaysian Certification
HACCP & only Scheme for HACCP only
SIRIM QAS International
Food Safety System
Certification Scheme
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
company’s 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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