APPLICATION FORM FOR

AQUACULTURE STEWARDSHIP COUNCIL (ASC)

FOR CUP INSPECTION & CERTIFICATION

with this form you can apply for a free offer for the audit and certification of your aquaculture operation for the farm ASC certification programme

NAME OF COMPANY APPLYING AND LEGAL STATUS
(please use full name of company with e.g. Ltd., Inc, SAC, SA, SARL, BV) /
ADDRESS OF COMPANY
(Street, post code, town, province, country, P.O. Box)
COMPANY’S LEGAL REPRESENTATIVE
(name of person and function) / COMPANY’S CONTACT PERSON
(complete if different from Legal Representative)
TELEPHONE / FAX NUMBER
/
E-MAIL (and/or website)
Our company is applying for the first time
Our company wishes to indicate changes to our existing project(s)
Our company is already certified and wants to transfer
Our company is applying for recertification
Our company is applying for :
ASC single site(single aquaculture site)
ASC cluster of sites (All of the sites have: a common management structure, subject to the same standard, the same production system and share resources or infrastructure or Share a landscape unit)
Tilapia / Latin name:
Abalone / Latin name:
Salmon / Latin name:
Shrimp / Latin name:
Pangasius / Latin name:
Bivalves / Latin name:
Fresh water trout / Latin name:
Cobia/Seriola / Latin name:

1. Company background

Please describe below a brief description of the activities you wish to have certified (hatchery, grow
out, processing, trading, production system).
Describe the legal information (List of entities).
Make a list of towns or populations near to the farm.

2. Production Units

Please describe below all production units that will undergo to the ASC farm certification.If it concerns changes mention all the units and indicate which one is changed, added or withdrawn.

NOTE: Sites that are contiguous will not be audited or certified as separated units.

Name of unit / Production system (i.e. cages, ponds, tanks, etc) / Production
(Ton) / Total Area (ha) / Location
(Detail the location with GPS coordinates and attach a satellite image or map were the location of the unit(s) is described) / Receiving water body (RWB)
(Detail the name of the RWB and attach a satellite image or map were the location of the receiving water is described) / Changed, added or withdrawn
(if applicable)
GPS Coordinates:

If there are production units owned by the same legal entity and that would not undergo to ASC farm certification please make a list with location below:

Name of unit / Location
If you are applying for cluster of sites, briefly describe the structure of the management system that
controlsthe compliance of the ASC standards and what resources, infrastructure , receiving water body or
watershed are shared by the units

3. Has the farm located in a protected area?

If YES, please identified the PA and the IUCN category following the website:

Please enclose relevant documents concerning the designation of permission for concessional areas (Environmental license, declarations, etc.)

4. Post-harvest operations

Please describe below the post-harvest operations taken place while the certified products stays in your ownership. This operation includes owned or subcontracted post-harvest handling or processing, transhipments, etc. The post-harvest operations must apply for the ASC products MSC chain of custody certification if the products will enter to further certified chains of custody.

Name of unit
/ Location / Owned or subcontracted by the applicant / Not ASC products are handled? Yes/no / ASC Chain of custody certified? Yes/no, certificate number

5. Please describe the access to each of all units mentioned,e.g. travel time between the different units, and time from nearest airport, etc.

Travel time between units, if applicableestimated time needed for travelling from nearest airport etc.

6. Has the project ever been registered, inspected or certified before by aCompliance Assessment Body (CAB) for ASC farm certification? For any other quality management system certification?

If YES, please mention: the name of the CAB, year of application, the previous registration number, reason of changing CAB, copy of expired, terminated or valid certificate. Please enclose relevant documents concerning the previous inspection(s) / certification(s) (inspection report, certificate etc.). Also detail if is the first or second transfer between the validity period established by the first CAB.

6. Stakeholders

Please make a list of all your potential stakeholders. CU office will invited them to participate in the initial audit. (NGO, neighbour, governmental authorities, veterinary authority, environmental authority, etc)

Type of stakeholder / Name/ Contact person / Address / Email / Phone number
Neighbour
Governmental authorities
Veterinary authority
Environmental authority
Others:

7. Employee information

N° of workers:

N° of Living on site:

N° subcontractors:

Local language:

NAME COMPANY
LEGAL REPRESENTATIVE (The person of the company, accepted by the Chamber of Commerce registration as assignment authorized)
DATE & SIGNATURE

Based on the above information, Control Union Certifications will draw up a no-obligation offer for a contract.

CU OFFICE USE ONLY! REVIEW of APPLICATION / Yes/No / Comment
Is the information in application form sufficient to make an offer (e.g. filled in completely, signature present and signed by the company requesting certification)? / (if no, give reasons)
Is it possible for CU to inspect and certify the project (e.g. sufficient inspection and expert inspectorcapacity, product within scope, location, language)? / (if no, give reasons)
Conclusion:Can an offer be made to the Company?
If one or more answered with NO, offer is not possible!
Assessed by: / Date:

Attach extra sheets if needed

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ASCAPPL.F01 (04) Control Union Peru SAC Av. Petit Thouars 4653, Piso 6 – Miraflores • Lima • Perú

Tel.: + 511-7190400 Fax: +511-7190410