RAW MATERIAL QUESTIONNAIRE

flavouring preparation

Product : Operator :

Supplier :
Sent on :

SUPPLIER :     TECH-VINA Joint Stock Company 

ADDRESS : Binh Dan Village, Tan Dan Commune, Khoai Chau District, Hung Yen Province,
Vietnam     
     
     

E-mail address : info@techvina.vn     

Web site : http://techvina.vn/     

Phone Number :   +84 866 115 386   

Fax Number :      

Are you the Manufacturer ? Yes No

If not, name of the MANUFACTURER  :      

VALIDATION
The Supplier guarantees that all information given in this questionnaire is accurate and valid and commits
itself to inform Argeville Flavour SAS in case of any modification

Date : Name : Stamp of the Company

Function :
Signature :

1 – IDENTIFICATION
TRADE NAME :      

SUPPLIER PRODUCT REF . :      

PRODUCT DESCRIPTION :      

Is the product suitable for use in ? Yes No

Customs tariff number foodstuffs      

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2 – COMPOSITION

Please detail the composition of your product in order that the total of the flavouring part (if any) and non
flavouring part (if any) is 100 %

2.1. Flavouring ingredients (as defined by the Regulation (EC) 1334/2008, article 3)
flavouring preparation(s) …………………:       %

The flavouring preparation is :

100 % pure and natural raw-material ,from certified origin :

Botanical name :
Country of origin :

100 % Pure and natural raw-material , from different origins

Mixture of various 100 % pure and natural raw-materials

Other (please specify) :      

2.2. Non flavouring ingredients

The product does not contain any additive. Yes No

Please state all non flavouring ingredients (Carriers, Foodstuffs, additives, colours..) also those which no
longer have any technological effect. Please state with denomination, %, E number for additives, specify the
source (animal/vegetable/ mineral) and the geographical origin
If there is no entry, then the supplier guarantees the absence of any additive in the product.
Denomination E No. % Source Country of origin
Example : Tocopherol-rich extract E 306 0,1 Soja USA
                             
                             

3 – Technical information

3.1 Process
Origin of the raw material
Vegetable
Nature :

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Animal
Nature :

Microbiological ( ex:yeast)
Nature :

Mineral

Other
Please specify :

Country of origin (site of production)

The raw material has been treated by traditional food- Yes No

preparation processes

The product is obtained by Physical process

Microbiological process
Enzymatic process

In the case of enzymatic process, do you confirm Yes No Not Applicable

that you will be submitting dossiers for all the
enzymes either contained in or used for the
manufacturing of ingredients until March 2015.

Could you precise Enzyme name, Source, IUBM

Number

We commit ourselves not to use, either chemical Yes No

catalysts or chemical agents during the
manufacturing process of this substance

The product has been treated with ionised radiations Yes No

This raw material contains Ethyl Alcohol intentionally Yes No

added
If yes give the quantity:

Does this product contain Palm oil or Palm oil Yes No

derivatives?
If Yes Please supply a RSPO Certificate

3.2 Physical and chemical criteria

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Specific gravity (20°C)

Refractive index (20°C)
Purity
Liquid
Powder

3.3 Microbiological criteria method

Meso.Aerob.plate count (CFU) : 10 000/g PCA, 72h/30°C

Coliforms : 100/g LST, 48h/30°C
E.Coli : neg/g BGBL, 48h/30°C
Salmonella : neg/50g AOAC
Yeast and Moulds 100/g OGA

3.4. Nutrional Values

Moisture (%):
Ash (%) :
Organic acids (%):
Ethanol (%) :

Carbohydrates (%) :
of which Fiber :

Proteins (%) :

Lipides (%) :
trans fatty acid :

Glucides (%) :
of which Sugar

Natrium (%) :

Calorific value : --- Kcal /100g

Energy value :--- Kj/100g

4- Storage conditions
Light protected and airtight, under cool and dry conditions. Temperature not exceed
30°C

5- Shelf life
24 months in unopened container , under recommended storage conditions.

6 – REGULATORY INFORMATION
CAS number      

EINECS number      

CoE number      

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The product is FEMA and/or FDA GRAS (Generally Yes No Not applicable
Recognised as Safe)

FEMA number      

USA Food and Drug Act, title 21, CFR § (Code of      
Federal Regulation paragraph)

The product is compliant with FCC (Food Chemical Codex)

USP (US Pharmacopoeia)
EP (European Pharmacopoeia)
Other, please specify :

Legal status in Europe      

Legal status in the USA      

The product is compliant with all applicable Yes No

regulations in Europe

If the product contains an additive, does it comply Yes No Not applicable

with the Directives 1333/2008 and 231/2012 as
modified ?

The product is a recovery flavouring according to Yes No Not applicable

Directive 2001/112/EC

The product is a recovery flavouring according to the Yes No Not applicable

AIJN Guidelines (water, food grade CO2 and ethanol
derived from non GMO foodstuffs may only be used
as solvents and also in extraction)

Substances listed in the Annex III-B of the Regulation 1334/2008 : Does the product contain any of the
following substances ?

Yes  No  N/A 
Please specify the maximum content :

Substance Present Max (mg/kg) Substance Present Max (mg/kg)

Agaric acid Yes  Quassine Yes 
Aloin Yes  Safrole and isosafrole Yes 
Beta asarone Yes  Santonin Yes 
Berberine Yes  Thuyone (alpha and beta) Yes 

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Coumarin Yes x Estragole Yes 

Hydrocyanic acid Yes  Menthofurane Yes 
Hypericine Yes  Capsaicine Yes 
Pulegone Yes  Methyleugenol Yes 

7 – CONTAMINANTS AND IMPURITIES

Residual solvents
The product is compliant with the Directive 88/344/EEC as Yes No Not applicable
modified concerning extraction solvents
Please specify type and amount of residual solvent (mg/kg)

Are other solvents used during the manufacturing process. ? Yes No

Please specify type and amount of residual solvent (mg/kg)

Heavy metals *
The product is compliant with the requirements of the Yes No Not applicable
Regulation (EC) 1881/2006

Pesticides *
The product is compliant with the MLRs set in the Regulation Yes No Not applicable
(EC) 396/2005

Mycotoxins *
The product is compliant with the requirements of the Yes No Not applicable
Regulation (EC) N° 1881/2006

Dioxins and PCBs *

The product is compliant with the requirements of the Yes No Not applicable
Regulation (EC) N° 1881/2006

PAH (Polycyclic aromatic hydrocarbons) *

The product is compliant with the requirements of the Yes No Not applicable
Regulation (EC) N° 1881/2006.
* If YES, many thanks to send us, attached with this Product Questionnaire, a Certificate of Analysis from a
batch representative of the delivered quality.
The representative Certificates Of Analysis will be sent to Argeville Flavour SASonce a year.

Unauthorized dyes
For Chilli, Capsicum, Curry, Curcuma, palm oil
containing or derived products only
Yes No Not applicable
The product or its raw material has been analysed to
guarantee that it does not contain any detectable
quantity of the following dyes
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Sudan I (CAS n° : 842-07-9)

Sudan II ( CAS n° : 3118-97-6
Sudan III (CAS n° : 85-86-9)
Sudan IV (CAS n° : 85-83-6)
Para Red (CAS n° : 6410-10-2)
Sudan Orange G (CAS n° : 2051-85-6)
Sudan Red 7B (CAS n° : 6368-72-5)
Sudan Red B (CAS n° : 3176-79-2)
Orange II (CAS n° : 633-96-5)
Rhodamine B (CAS n° : 81-88-9)
Butter Yellow (CAS n° : 60-11-7)
Bixin (E 160b) (CAS n° : 1393-63-1)
The analysis has been made by a ISO 17025
accredited laboratory
Yes No Not applicable
The certificate of analysis will be sent to Argeville
flavour SAS with each delivery
Yes No Not applicable

Packaging :
Packaging description : …………………………………………………………………………………

The packaging is in accordance with :

- Regulation (EC) No 1935/2004/CE of 27th October 2004 on material and articles intended to come into
contact with food; ☐ YES ☐ NO

- Regulation (EC) No 2023/2006 of 22nd December 2006 amended on good manufacturing practices for ma-
terials and articles intended to come into contact with food; ☐ YES ☐NO

- French regulation in force concerning materials and articles intended to come in contact with food, that is to
say sanction decree No 2007-766 of 10th may 2007, amended by the decree No 2008-1469 of 30th Decem-
ber 2008; ☐ YES ☐NO

- Specific regulations :
e.g.: Regulation (EC) No 10/2011 in the case of a plastic material
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………

This declaration of compliance has been established on the following (tick the appropriate boxes, if con-
cerned):
 Declaration(s) by suppliers of raw materials
 Migration testing
If necessary, supplier may be required to forward results of packaging migration tests.

8 – TSE/BSE
The product does not contain any ingredient obtained Yes No Not applicable
from specified risk material according to the
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Regulation (EC) N° 999/2001

The product is compliant with the Regulation (EC) Yes No Not applicable
N° 999/2001

9 – DIETS
Vegan Yes No Vegetarian Yes No

Coeliac Yes No Diabetic Yes No

10– SAFETY DATA

Is the product dangerous according to the Directives Yes No
1272/2008 as modified ?

If yes, please enclose your current Material Safety Data Sheet

11– ALLERGENS
Please indicate the presence of any allergens in the following table by Yes or No.

11.1. Allergens according to the Directive 2007/68/CE

Contamination within your

Cross-contamination within your plant
Allergens supplier’s plant
intentionally Cross-
added in the contamination Presence Presence in Presence
ALLERGENS
supplied Presence
risks of the raw during your during
product within your
materials in transport to production transport to
factory
your supplier’s your plant lines our plant
plant
Cross-contamination risks of
the raw materials in your Yes No Yes No Yes No Yes No Yes No Yes No
supplier’s plant
Peanuts and peanut
derivatives
Eggs and derivatives
Milk and derivatives (including
lactose)
Crustaceans and derivatives
Fish and derivatives
Soybeans and derivatives
Cereals containing gluten
(wheat, rye, barley, oats, splet,
kamut or their hybridised
strains) and derivatives
Sesame seeds and derivatives
Other nuts (Cashew, Walnut,
Hazelnut, Brazil, Pistachio,
Almond, Pecan, Macadamia
and Queensland) and
derivatives

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Contamination within your

Cross-contamination within your plant
Allergens supplier’s plant
intentionally Cross-
added in the contamination Presence Presence in Presence
ALLERGENS
supplied Presence
risks of the raw during your during
product within your
materials in transport to production transport to
factory
your supplier’s your plant lines our plant
plant
Cross-contamination risks of
the raw materials in your Yes No Yes No Yes No Yes No Yes No Yes No
supplier’s plant
Mustard and derivatives
Celery and derivatives
Sulphur dioxide and
sulphites (at concentrations >
10 mg/kg or 10 mg/l expressed
as SO2)
Lupin and derivatives
Molluscs and derivatives

In case of Yes, please specify bellow the name of the source of allergen and its quantity :
-
-
-
11.2. Other allergens and intolerances
Contamination within Cross-contamination within your
Allergens your supplier’s plant plant
directly Cross-
added (raw contaminati
Presence Presence
material or on risks of Presence in Presence
during during
derivatives) the raw your within
transport transport
in the materials in production your
to your to our
supplied your lines factory
plant plant
formula supplier’s
plant
Yes No Yes No Yes No Yes No Yes No Yes No
Beef
Pork
Chicken
Animal fat
Vegtable Fat
Cocoa
Caffeine
Cinnamon
Yeast
Vanillin
Fructose
Sucrose
Benzoic acid (E210  E213)
Sorbic acid (E200  E203)

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Contamination within Cross-contamination within your

Allergens your supplier’s plant plant
directly Cross-
added (raw contaminati
Presence Presence
material or on risks of Presence in Presence
during during
derivatives) the raw your within
transport transport
in the materials in production your
to your to our
supplied your lines factory
plant plant
formula supplier’s
plant
Yes No Yes No Yes No Yes No Yes No Yes No
p-Hydroxybenzoate (E214  E219)
BHA / BHT (E320-E321)
Amaranth (E123)
Azorubine, Carmoisine (E122)
Brilliant Black (E151)
Sunset yellow (E110)
Ponceau 4R (E124)
Tartrazine (E102)
Glutamate added
Glutamate natural
Glutaraldhehyde
GMP added
GMP natural
IMP added
Phenylalanine
Vegetables
Maize/Corn
Rice
Umbelliferae
Salt ( as NaCl)
Salt ( added)
Yeast
Hydrolysed Plant Protein
Umbelliferae
Carrot
Cinnamon
Coriander
Fruit
Garlic
Gelatin
Pulses
Honey

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Contamination within Cross-contamination within your

Allergens your supplier’s plant plant
directly Cross-
added (raw contaminati
Presence Presence
material or on risks of Presence in Presence
during during
derivatives) the raw your within
transport transport
in the materials in production your
to your to our
supplied your lines factory
plant plant
formula supplier’s
plant
Yes No Yes No Yes No Yes No Yes No Yes No
Safran
Gallate ( E310-E312)
Nitrite (E249-E252)****
IMP natural
Coconut
Colza

In case of Yes, please specify the name of the source and the quantity :
-
12 – GMO
According to the EU regulations concerning the traceability and labelling of Genetically Modified Organisms
(GMO), and the traceability of food products produced from GMO (Regulation N°1829/2003/EC and
N°1830/2003/EC and amendments), we confirm that the product :

12.1  Contains ingredient(s) from Maïze and/or Soya origin Yes No

If Yes, Please send us an up to date IP certificate

 is GMO or contains or consists of GMOs Yes No

 is produced from GMOs or contains ingredients produced

Yes No
from GMOs

 This raw material is in compliance with following conditions: -

this product does not contain GMOs ingredient in proportion
Yes No
higher than 0.9%. This presence is adventitious or technically
unavoidable

12.2  Contains ingredient(s) from other potential GMO-risk raw Yes No

material(s) (rice, beet, cotton …)

If Yes, please specify :

o ingredient :
o vegetable origin :
o geographic origin :

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 This raw material is in compliance with following conditions: -

this product does not contain GMOs ingredient in proportion
Yes No
higher than 0.5%. This presence is adventitious or technically
unavoidable

12.3 For information about processing aids,

 is produced or contains ingredient(s) produced
Yes No
with GMOs or Genetically Modified Microorganisms processing aids
(bacteria, yeast…) or derived from GMOs or GMMs (including
enzymes)

If yes, please specify :

We confirm that the ingredient supplied is compliant in all respects with the
Yes No
Regulations N°1829/2003/EC and N°1830/2003/EC where applicable

We will inform Argeville Flavour SAS immediately in written form, if there

Yes No
are any changes concerning this certificate

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