MATERIALS USE REQUEST FORM FOR MANUFACTURER

ECOCERT ICOPage 1/3

(To be completed by the input manufacturer)

To Whom this May Concern:

ECOCERT ICO is a USDA Accredited Organic Certifying Agency (ACA). You are being sent this form as a result of an ECOCERT ICOclient who is requesting permission to use one or more of your products. ECOCERT ICO does not perform materials reviews for any product unless its use is requested by an ECOCERT ICOclient, who has submitted a complete application and application fee,

Necessary Information:

In order for ECOCERT ICOto evaluate the status of an input for use in organic production or handling under current USDA/NOP regulations, we require certain information that is necessary for our review. Our forms are attached.

Please complete one form for each product named in our client’s request. Incomplete applications cannot be processed.

Confidentiality:

We appreciate and respect privileged information. ECOCERT ICOis willing to sign a confidentiality agreement and keep private all information shared on these materials. Organic operations and certifiers are required to ensure that no prohibited products are used in organic production and handling.

Without information on ingredients, we cannot evaluate compliance.

Reviews by another agency:

For a material to be allowed, it must be reviewed to 7 CFR Part 205 and/or other standards as applicable to the client’s request. ECOCERT ICO is currently under contract with OMRI and accepts their determinations.

If you chose not to provide information:

In cases where manufacturers refuse to provide ECOCERT ICOwith the information necessary for us to evaluate a material for compliance with CFR 205, it is ECOCERT ICO’s policy to direct the client not to use such products.

All information must be complete and form must be signed. If you have any questions, please let us know.

Thank you in advance for your cooperation!

ECOCERT ICO LLC

PC Box 158

Plainfield, IN 46168,

Tel: (317) 865-9700 - Fax: (317) 708-0628

Email:

Website:

1-- Information on the manufacturer of the product

Company Name:Contact person:

Address:

Email:Phone/Fax:

Name of ECOCERT ICO certified operation:

2-Information on the product

Brand Name of Material/Product / Generic Name of Material

Specific Uses of Material (Check all that apply):

FertilizerHomeopathic medicinesSoil conditioner

Feed additive InsecticideAnimal medication

FungicideDisinfectant/sanitizing agentBactericide

CleanserRodenticideRipener

Plant grow regulatorFood additiveSeed or Planting stock treatment Processing aids Mineral soil amendment

Vitamin or Mineral (FDA approved only)Organic matter amendment

FlavorManure containing fertilizerManure treatment

Micro-organisms

Other:

3-Description of the product (all of the ingredients are required to be listed)

Ingredient’s name / Kind of Ingredient (Active/inert) / Chemical name / CAS number / % of total contents / Origin (synthetic/non synthetic)
TOTAL : / 100%

List any ingredients made from GMO’s (Genetically Modified Organisms) or produced/extracted from GMO’s:

Please attach a copy of all labels for product to be reviewed. ☐Attached

4-For composted animal manures (Fertilizer), please, describe the composting process

Compost made using an in-vessel or static aerated pile system

Compost made using a windrow composting system

Peak Temperature:

Initial C/N ratio (Carbon/Nitrogen):

Peak Temperature duration:

Composting duration:

How many times is the compost turned?

Over how many days does the turning take place?

Quick description of the process:

The information contained in this questionnaire will be treated as strictly confidential between the manufacturer and ECOCERT ICO. The operator on whose behalf this information is provided will receive only the official result of this verification. By signing, the manufacturer declares that all information provided is correct and complete to the best of his/her knowledge.

This document is not a certificate or an attestation about the conformity of the product described above with NOP organic regulation. Therefore, this document must not be used for any commercial purposes or to attest the product was verified by ECOCERT ICO to be used on organic production.

Date:

Name of Materials/Input Manufacturer:

Signature :

Approval / Form’s code / Last update
CM / F11 (v3) (f) / 12/12/11