Appendix 6
Ministry of Health Malaysia
APPLICATION FORM FOR THE COMPLIANCE LISTING OF SOURCE OF ICE
IN THE EXPORT SUPPLY CHAIN
1.0 Type of Application(1): New Re-apply
Others, please specify …………………………………………………………
2.0 Particulars of Applicant
2.1 Name of Applicant: ……………………………………………………………………………………………….………….
2.2 NRIC Number: …………………………………………………………………………………………………………………
2.3 Name and Address of Company: ………………………………………………………………………………………...
......
2.4 Tel. No.: …………………………… 2.5 Fax No.: ……………………………… 2.6 H/P No.: ……………………….....
2.7 E-mail address: ……………………………………………………………………………………………………………….....
2.8 Company Registration Number (ROC): ………………………………………………………………………………..
(Please attach copy of the certificate)
2.9 Licence Number (Issued under regulation 394A of Food Regulations 1985 -Standard for wholesome
ice)(Please attach copy of the licence): …………………………………………………………......
2.10 Address / Location of Source of Ice: ……………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
Postcode :……………………….. District: ………………………………………. State :………………………......
2.11 Correspondence Address (if different from para 2.3): .……………………………………………………………..
………………………………………………………………………......
(1) Tick () where appropriate
3.0 Particulars of Source of Ice
3.1 Type of ice produced:(1) CubesFlakes Others, please specify......
3.2 Type of container used to transport ice:(1) Insulated boxOthers, please specify
……………………………………
3.2 Registration number of transport vehicle used to transport ice in the supply chain:
i) ……………………………………......
ii) ……………………………………......
iii) ……………………………………......
Please provide the information in a separate annex if the available space is inadequate
4.0 Particulars ofIce Handlers
4.1 Have the ice handlers been medically examined in accordance to the Guideline for Medical Examination for Food Handlers in Fishery Product Industries in Malaysia which is available at the website ?(1)
YesNo
If yes, please attach the names of the ice handlers and the copies of their medical examination reports as in Appendix II of the guideline.
4.2Have the ice handlers attended any training on basic hygiene?(1)
YesNo
If yes, please attach the names of the ice handlers, name and date of training,name of trainer and training institution.
(1) Tick () where appropriate
5.0 Requirement forSource of Ice
5.1 Compliance listing is subject to the compliance with the Food Hygiene Regulations and importing countries’ requirements.
5.2 Applicant shall submit relevant document i.e. Standard Operating Procedure of Source of Ice which is to be based on Food Safety Assurance Programme such as HACCP, Good Manufacturing Practices or Good Hygiene Practices.
6.0 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 complywith the importing countries’ requirements for fishery products.
………………………………....
(Signature of Applicant)
…………………………………………...... …………………………………
(Name of Applicant) (Company stamp)
………………………………..
(Date)
7.0 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 :03-88833558
Fax. No :03-88893815
FOR OFFICIAL USE ONLY
8.0 Result of Inspection (to be completed by the inspector)
Complying
Source of ice is recommended to be listed
Non-complying
Remarks:......
......
Final inspection report attached
Signature:......
Name of inspector:......
Date:...... Official Stamp
9.0 Compliance Status (to be completed by Food Safety and Quality Division, Ministry of Health)
Comply
Not Comply
Remarks:......
......
Signature:......
Name of Officer:......
Date:...... Official Stamp