Appendix 7
Ministry of Health Malaysia APPLICATION FORM FOR THE COMPLIANCE LISTING OF EXPORT ESTABLISHMENT FOR EXPORT OF FISH AND FISHERY PRODUCTS 1.0 Type of Application(1): New Re-apply Others, please specify …………………………………………………………...
2.0 Type of Export Establishment(1): PP : Processing Plant ZV : Freezing Vessel PPAq : Plant also processing aquaculture product PP32 : Cold Store FV : Factory Vessel Others (please specify): …………………… 3.0 Particulars of Applicant
3.1 Name of Applicant: ………………………………………………………………………………………………….………
3.2 NRIC Number: …………………………………………………………………………………………………………………
3.3 Name and Address of Company: …………………………………………………………………………………….....
......
......
3.4 Tel. No.: ………………………… 3.5 Fax No.: …………………………… 3.6 H/P No. ……………………......
3.7 E-mail address: ………………………………………………………………………………………………………………..
3.8Company Registration Number (ROC): ……………………………………………………………………………….. (Please attach copy of the certificate)
3.9Company Licence Number: ...... (Please attach copy of the licence)
3.10 Address / Location of Export Establishment: ………………………………………………………………………
………………………………………………………………………………………………………………………………………….
Postcode :……………………….. District: …………………………………...... State :…………………………......
3.11 Correspondence Address (if different from para 3.3): . ………………………………………………………….
…………………………………………………………………………………………………………………………………………. (1) Tick () where appropriate 4.0 Food Safety Assurance Program in-place
HACCP Implementaion Certification*
GMP Implementaion Certification*
Others, please specify Implementaion Certification*
…………………………………………………………
5.0 Particulars of Food Handlers
5.1 Have all the food handlers been medically examined in accordance with the Guideline for Medical Examination for Food Handlers in Fishery Product Industries in Malaysia which is available at the website http://fsq.moh.gov.my ?(1)
Yes No
5.2 Have all the food handlers attended any food handlers training?(1)
Yes No
(1) Tick () where appropriate * Please state certification body 6.0 Source of Raw Materials for Fishery Products(2)
6.1 Captured Fishery Product (FP)
No Common Type of Species Registration Name and Name of Registration Name and Address of Name of FP Raw Material No. of Fishing Address of Address of No. of Independent (finfish, Vessel Landing Site Middleman Transport Refrigerated Store crustaceans or Vehicle (chilled or frozen), if any cephalopods)
Please provide the information in a separate annex if the available space is inadequate
6.2 Aquaculture Fishery Product (FP)
No Common Type of Species Name and Address of Name of Address of Registration No. of Name and Address of Name of FP Raw Material Aquaculture Farm Middleman Transport Vehicle Independent (finfish or Refrigerated Store crustaceans) (chilled or frozen), if any
Please provide the information in a separate annex if the available space is inadequate
(2) To be completed where appropriate 6.3 Fishery Product (FP) Processed Using Imported Fishery Raw Material (Including Semi-Processed Fishery Raw Material)(3)
No Common Type of Species Captured Aqua- Country Foreign Supplier Registration Name and Address of (1) (1) Name of FP Imported Fishery culture of Name and Address of No. of Independent Fishery Origin Transport Refrigerated Store Processing Establishment Raw Vehicle (chilled or frozen), if any Material
Please provide the information in a separate annex if the available space is inadequate
6.4 Fishery Product (FP) Processed Using Locally Produced Semi-Processed Fishery Raw Material
No Common Name of Type of Semi- Species Name and Address of Registration Name and Address of Independent FP Processed Establishment Processing No. of Refrigerated Store (chilled or Fishery Raw Semi-Processed Fishery Transport frozen), if any Material Raw Material Vehicle
Please provide the information in a separate annex if the available space is inadequate
(1) Tick () where appropriate (3) Application for compliance listing shall be made using “Application Form for the Compliance Listing of Sources of Imported Fishery Raw Materials in the Supply Chain” 7.0 Source of Ice
No Name and Address of Location Licence Number Type of Ice(4) Registration No. of Transport Vehicle
Please provide the information in a separate annex if the available space is inadequate
(4) Cubes/Flakes/Others, please specify 8.0 List of Importing Countries and Products
Please specify product(s) to be exported :
Name and Type of Exported Name of Products (finfish, Processing type / Name and Address of No. Importing Species crustaceans or activity (5) Importers Country cephalopods)
Please provide the information in a separate annex if the available space is inadequate
(5) RW = raw ; L = filleting ; S = salted; K = smoked ; M = marinated; CN = canned; F = freezing; C = chilling; H = heading; G = gutting; W = wrapping; HT = heat treatment; O = other (please specify) 9.0 Transport Vehicle
To be filled up by export establishment which is applying for compliance listing of transport vehicle owned by the export establishment. i) Particulars of Transport Vehicle
9.1 Number of worker(s) including driver(s): ………………………………………
9.2 Name and NRIC Number of worker(s) including driver(s):
No. Name NRIC No.
Please provide the information in a separate annex if the available space is inadequate
9.3 Registration number and type of transport vehicle to be used in the export supply chain:
No. Registration No. of Transport Vehicle Type of Vehicle (2)
Please provide the information in a separate annex if the available space is inadequate
9.4 Type of container used to store fishery raw materials: (1) Insulated box Others, please specify ……………………………………………
9.5 Source of Ice for transport:
Name and Address of Type of Container Used Type of Ice (4) Ice Supplier to Transport Ice (3)
Please provide the information in a separate annex if the available space is inadequate (1) Tick () where appropriate (2) Refrigerated truck / covered lorry / others, please specify (3) Insulated box / others, please specify (4) Cubes / flakes / others, please specify 10.0 Middlemen
To be filled up by the export establishment which is applying for compliance listing of middlemen who supply raw materials for the processing of fishery products in the establishment. A separate form is to be filled for each middleman. Please provide the information in a separate annex if the available space is inadequate. i) Particulars of Middleman
Company Name : Address : Owner Name : Owner I.C. No. : Tel. No. : Fax No. : Email :
10.1 Number of worker(s) : ………………………………………
10.2 Name and NRIC Number of worker(s) :
No. Name NRIC No.
Please provide the information in a separate annex if the available space is inadequate
10.3 Address of Fish Collection Centre (s) (if applicable) :
No. Fish Collection Centre Address
Please provide the information in a separate annex if the available space is inadequate 10.4 Registration number and type of transport vehicle to be used in the export supply chain:
No. Registration No. of Transport Vehicle Type of Vehicle (2)
Please provide the information in a separate annex if the available space is inadequate
10.5 Type of container used to store fishery raw materials: (1) Insulated box Others, please specify ……………………………………………
10.6 Usage of Ice Yes No
10.7 If yes, please state the source of ice to be used in the export supply chain:
No. Name and Address Name and Licence Type of Type of Registration No. of Location Address of Number Ice (3) Container Used of Transport Ice Supplier to Transport Vehicle Ice(4)
Please provide the information in a separate annex if the available space is inadequate
(1) Tick () where appropriate (2) Refrigerated truck / covered lorry / others, please specify (3) Cubes / flakes / others, please specify (4) Insulated box / others, please specify 11.0 Applicant shall submit documents as follows:
HACCP / GMP Certificate (if the establishment is HACCP / GMP certified);
Any other appropriate supporting documents. List of supporting documents: …………………………………………………………. …………………………………………………………. ………………………………………………………….
12.0 Applicant Declaration
I , ………………………………………………………………………………. (Name of Applicant)
Declare that:
the information supplied in this application is true ; fully committed to comply with the Food Hygiene Regulations 2009 and have undertaken necessary measures to comply with the importing countries’ requirements for fishery products.
……………………………….... (Signature of Applicant)
…………………………………………...... ……… …………………………… (Name of Applicant) (Company Stamp)
……………………………….. (Date)
13.0 Please return completed application form to:
Senior Director Food Safety and Quality Division Ministry of Health Malaysia Level 3, Block E7, Complex E, 62590 Putrajaya Tel. No :03 – 8889 3501 Fax. No :03 – 8889 3815 FOR OFFICIAL USE ONLY
14.0 Result of Inspection (to be completed by the auditor) a) Transport vehicle
No. Registration No. of Complying Non-complying Remarks Transport Vehicle
Final inspection report attached
Signature :......
Name of Inspector :......
Date :...... Official Stamp
b) Middlemen
No. Company Name of Complying Non-complying Remarks the Middleman
Final inspection report attached
Signature : …………………………………………………….. Name of Inspector : …………………………………………………….. ……………………….. Date : ……………………………………………………... Official Stamp c) Establishment
Complying Establishment is recommended to be listed
Non-complying
Remarks:......
Final inspection report attached
Signature :......
Name of Inspector :......
Date :...... Official Stamp 15.0 Compliance Status (to be completed by Food Safety and Quality Division, Ministry of Health) I. Transport vehicle
No. Registration No. of Complying Non- Remarks Transport Vehicle complying
Signature :......
Name of Officer :......
Date :...... Official Stamp
II. Middlemen
No. Company Name of Complying Non-complying Remarks the Middleman
Final inspection report attached
Signature : …………………………………………………….. Name of Officer : …………………………………………………….. ……………………… Date : ……………………………………………………... Official Stamp III. Establishment
Comply
Not Comply
Remarks
......
Signature :......
Name of Officer :...... ……………………….
Date :...... Official Stamp