Application Form

To find out the condition of your Company / Organization, in providing the right value before
starting the validation / verification / certification process, we would like to ask your cooperation
to fill this form as complate as the instructions we provided. As a Validation / Verification /
Certification Body, we keep the confidentiality of the information you provided through this
application form.
Part 1: A company name information / Organization
1.1. ORGANIZATION NAME (Company, Association, etc.):

Company Name (which will be displayed on the contract):

Address:

City: Province/State: Zip Code:

Country:

Website:

Type of business:

1.2. CONTACT PERSON WHO WILL SIGN THIS CONTRACT

First Name: ☐ Mr. ☐ Mrs. ☐ Ms. Last Name: Position:

Contact Number: Email:

1.3. COMPANY AFFILIATES FOR OTHER ENTITIES (Subsidiary / branch company)

Company Name: Relationship with the company:

Is there any cooperation previously between your company and PT Mutuagung Lestari?

Yes No

If yes, what kind of services that you used?

1.4. COMPANY ORGANIZATION CHART

ISCC-4001.1 Page 1 of 4
Mutu Certification International
Jl. Raya Bogor Km. 33,5 No. 19, Cimanggis, Depok 16953
Telp: (021) 8740202, Fax: (021) 87740745 / 87740746, Email: ghgservices@mutucertification.com
Website: http://www.mutucertification.com
 Application Form
Part 2: Business Process / Business
2.1 Description of business flow chart/business process (input to output)

2.2 Information on certification scope and the facilities use

Certification Scope

(e.g Farm/Plantation, First Gathering Point, Central Office,

Point of Origin, Collecting Point, Warehouse, Logistic Centre,
Trader with storage, Trader, MTBE Plant, ETBE Plant,
Processing Unit etc.)

Type of material with annual volume (MT)

Number of facilities use and address

(e.g. storage, farm/plantation, factory, warehouse etc.)

Furthest distance facility from office to your storage

2.3 Description of suppliers

Type of supplier with number of each supplier

Type of material supplied

For waste/residue

Information on Point of Origin/Supplier:

 Is there any supply more than 10 mt/month or 120

mt/year?

 If any supplier supply more than 10mt/month or 120

mt/year, how many supplier supply more than 10
mt/month or 120 mt/year?

 If there is any supplier supply more than 10 mt/month or

120 mt/year, what is the furthest distance of those
supplier to your storage?

 If there is any supplier supply more than 10 mt/month or

120 mt/month, is the supplier has been ISCC certified as
Point of Origin?

Information on Dependent Collecting Point (DCP):

ISCC-4001.1 Page 2 of 4
Mutu Certification International
Jl. Raya Bogor Km. 33,5 No. 19, Cimanggis, Depok 16953
Telp: (021) 8740202, Fax: (021) 87740745 / 87740746, Email: ghgservices@mutucertification.com
Website: http://www.mutucertification.com
 Application Form

 Is there any DCP used under control of Collecting Point?

 If there is any DCP used:

- how many DCP is used?
- are DCPs located in the same country?
- if located in the same country, how many hours of
travelling to the DCP location from the Collecting
Point address?

Part 2.3 Further information required for farm/plantation industry

Is there any land clearing for new planting after 2008?
Yes No

If yes, please describe the name of the management unit:

If yes, is there any operational area overlapped with no go area category of grass tool? :

Is there any peat-land area?

Yes No

If yes, please describe the hectare of the peatland :

If yes, please describe when the peatland area was converted into farm/plantation?
(year of the latest land clearing):

Part 2.4 ISCC related information

If the Organization has been ISCC Certified.
ISCC registration no. :

Date of ISCC initial certification :

Type of GHG calculation use : Actual Value Default Value Disaggregated Default Value

Part 3: Total Annual Income

Please sign the annual earnings level for your operating unit in Euro currency.

Total Annual Income (Million Euro) Please Sign

1 (0€ -0.6€)

2 (0.6€ - 3€)

3 (3€ - 15€)

4 (15€ - 30€)

5 (30€ - 60€)

6 (60€ - 150€)

7 (150€ - < )

ISCC-4001.1 Page 3 of 4
Mutu Certification International
Jl. Raya Bogor Km. 33,5 No. 19, Cimanggis, Depok 16953
Telp: (021) 8740202, Fax: (021) 87740745 / 87740746, Email: ghgservices@mutucertification.com
Website: http://www.mutucertification.com
 Application Form

Part 4: Related Information of Certification Process

Mention the management system certificates that the company has been certified (eg : ISO 9001, ISO 14001 or OHSAS 18001)

ISCC Assessment plan (time/date):

ISCC Certification target (time/date):

Distance to site:
The nearest airport from the audit location Airport Name:
Traveling time (hour):

Comment or additional information:

Part 5: Authorization
Name of Company PIC on Application Form:

Position:

Signature (Electronic Acceptable):

Date/Month/Year:
If you have any questions about how to complete this form, please contact us:
Ms. Kiki Rizkina
Marketing Division
Telp: +62-21-8740202
email: astrid@mutucertification.com
krizkina@mutucertification.com
ghgservices@mutucertification.com

ISCC-4001.1 Page 4 of 4
Mutu Certification International
Jl. Raya Bogor Km. 33,5 No. 19, Cimanggis, Depok 16953
Telp: (021) 8740202, Fax: (021) 87740745 / 87740746, Email: ghgservices@mutucertification.com
Website: http://www.mutucertification.com