1. operator

Registration Number
(to be completed by FAMI-QS):
Company Name: / V.A.T.:
Address:
Postal Code: / City:
Country:
Quality Assurance Department / Contact Person:  Mr.  Mrs.
Email: / Telephone:
Crisis Management / Contact Person:  Mr.  Mrs.
Email: / Telephone:
Newsletter / Contact Person:  Mr.  Mrs. / Telephone:
Email:

2. INVOICING DETAILS

 AS ABOVE

Company Name: / V.A.T.:
Address:
Postal Code: / City:
Country:
Contact Person: /  Mr.  Mrs.
Email: / Telephone:

3. site to be audited

(For additional sites, please provide the same information requested as for site 1)
Company Name:
Address :
Postal Code: / City:
Country:
Contact Person: /  Mr.  Mrs. / Function:
Email: / Telephone:
  1. FAMI-QS SCOPE

SINGLE INGREDIENTS

“The primary responsibility for the correct classification of the specific product, lies with the feed operator under the control of the competent authority”

1. Please indicate the ingredient (active substance) you wish to evaluate: ______

2. Is the ingredient intended to be placed in the European (EU) market?

 No  Yes

If yes,

2a. Is the ingredient included under the European Register of Feed Additives?

Note: For ingredients to be placed in the European (EU) market, it is required that these ingredients are listed on the European Register of Feed Additives. The current version of the Register can be found under:

 No  Yes

IF YES, YOU DON’T NEED TO PROCEED FURTHER IN THE QUESTIONNAIRE.

3. Is the ingredient produced according to the following production processes (or their combination)?

 Chemical

 Bioprocessing

 Mining

 Extraction

Other

4. Does the supplier recommend the usage of the ingredient to achieve a specific functionality?

 No  Yes

4a. If yes, which ones?

Technological functionality

Substances added to feed for a technological purpose, e.g. preservatives; antioxidants; emulsifiers; stabilisers; thickeners; gelling agents; binders; anticaking agents; acidity regulators; denaturants and others.

Sensory functionality

Substances that improve or change the taste, texture, aroma of the feed, or the visual characteristics of the food derived from animals.

Nutritional functionality

Substances that add nutritional value to feed.

Zootechnical functionality

Substances added to feed to affect positively the performance of animals in good health or used to affect positively the environment.

 Other functionalities related to the specialty feed ingredients. Which? ______

[FILL THE ABOVE QUESTIONNAIRE FOR EACH SINGLE SPECIALTY FEED INGREDIENT]

  1. FAMI-QS SCOPE

MIXTURES

“The primary responsibility for the correct classification of the specific product, lies with the feed operator under the control of the competent authority”

1. Please indicate the product you wish to evaluate: ______

2. Is the product intended to be placed in the European (EU) market?

 No  Yes

FROM THE FOLLOWING DESCRIPTIONS (A, B, C or D), WHICH ONE CORRESPONDS TO YOUR PRODUCT PRODUCTION PROCESS?

A - Is the product a mixture of one or more specialty feed ingredients with feed ingredients or water used as carriers, intended to optimize their mixing in feedingstuffs, not for direct feeding of the animals?

 No  Yes

B - Is the product a mixture of one or more specialty feed ingredients and/or with or without other feed ingredients, for direct feeding of the animals, which, by reason of its composition, is insufficient for a daily ration?

 No  Yes

If yes, please provide the product’s composition (in a separate file).

B1 - Does the supplier recommend the usage of the product to achieve a specific functionality?

 No  Yes

If yes, which ones?

 Technological functionality

Substances added to feed for a technological purpose, e.g. preservatives; antioxidants; emulsifiers; stabilisers; thickeners; gelling agents; binders; anticaking agents; acidity regulators; denaturants and others.

 Sensory functionality

Substances that improve or changes the taste, texture, aroma of the feed, or the visual characteristics of the food derived from animals.

 Nutritional functionality

Substances that add nutritional value to feed.

 Zootechnical functionality

Substances added to feed to affect positively the performance of animals in good health or used to affect positively the environment.

 Other functionalities related to the specialty feed ingredients. Which? ______

C - Is the product a mixture prepared according to a specific procedure or formula in order to achieve effects that cannot be obtained from its components when these are used individually or to achieve a higher degree of effectiveness or to improve handling properties and safety for the user?

 No  Yes

D – Other

[FILL THE ABOVE QUESTIONNAIRE FOR EACH MIXTURE OF SPECIALTY FEED INGREDIENTS]

Your application form will be processed by FAMI-QS Feed and Food Services SPRL.

Please send this application form to both in a scanned version (with signatures) and in Word/PDF format, for data processing.

 By signing this duly completed application form, the Operator agrees that, as soon as they have received the invoice, they will pay the applicable service fee per site, which is indicated on the FAMI-QS website: Once it is paid, a letter of acceptance (Approval Letter) will be sent to you. The approval letter needs to be provided to the auditor. FAMI-QS Feed and Food Services will send the Operator all invoices by email, to the address associated with their account. The Operator is responsible for paying in a timely manner.

 I have read, fully understood, accepted and implemented the Rules for the Operators.

 I have read, fully understood, accepted and implemented the Crisis Management Procedure.

 I have read, fully understood, accepted and implemented the Surveillance Programme procedure.

Date:

Name and signature:

To be completed by FAMI-QS
Application:  Approved  Rejected / Date of Approval: __ _/____/____
Signature / Inform the operator: __ _/____/____
Signature
Notes: