ISO 22000/FSSC 22000 application form 
                                                                                                                           Kiwa VERIN B.V. 
                   Thank you for your interest in Kiwa!                                                                   Nevelgaarde 20d 
                   Please complete this form as fully as possible so that we can draw up a                            3436 ZZ Nieuwegein 
                   suitable quotation for you. If you have any questions about the issues,                                   Postbus 2703 
                   please get in touch at any time and we will be happy to help.                                     3430 GC Nieuwegein 
                                                                                                                    T: +31 (0)88 998 4310 
                                                                                                                      E: sales@kiwacmr.nl 
                     Company details 
                     Company name 
                     Legal business registration number 
                     (please also send a copy of an extract from the 
                     registration) 
                     Postal address/Postcode 
                     Postcode+town/city+country postal address 
                     Visitors’ address 
                    Postcode+town/city+country visitors'address 
                     E-mail address 
                     E-mail address for invoicing (if different)      
                     VAT Number 
                     Telephone number                                 Landline:                           Mobile: 
                     Contact person (name and job title) 
                     Advisor/consultant 
                     (If applicable)  
                     How did you come across Kiwa                     ☐  Through Google and/or the Kiwa website 
                     to request a quotation?                          ☐  Through mouth-to-mouth advertising 
                                                                      ☐  Through an advisor, namely:         
                                                                      ☐  Other, namely:        
                     Required certification 
                     For what standard are you applying for           ☐ ISO 22000 
                     certification?                                   ☐ FSSC 22000 
                     If applicable, date of last audit 
                     If applicable, date of last unannounced 
                     audit 
                     In which month do you prefer the audit? 
                     Other certification 
                     Are you currently in possession of a             ☐  Yes, namely                       Valid until 
                     system certification?                            ☐  No          
                     (for the requested scheme or otherwise) 
                              © Kiwa                              Version number 04: 04-04-2022                            Page 1 of 3 
                   ISO 22000/FSSC 22000 application form                                                                                       
                                                                                                                                          
                    Additional certification details for ISO 22000 and FSSC 22000 
                    Scope description/description of the             
                    activities (products, processes (including       
                    packaging) and/or services) to be certified      
                                                                     
                                                                     
                                                                     
                                                                     
                    Are there exclusions to the activities to be    ☐  Yes, namely                                
                    certified compared to the activities you        ☐  No 
                    carry out in relation to food products?  
                    Are activities outsourced?                      ☐  Yes, namely                                
                    If so, what activities?                         ☐  No 
                    For what category are you applying for certification? (in accordance with ISO/TS 22003:2013 table A.1) 
                    *: categories are offered, but these do not fall under the scope of accreditation 
                    ISO 22000                                                  FSSC 22000 
                       ☐ A I: Keeping animals for meat, milk, eggs and            ☐ C I: Processing of perishable animal products 
                       honey*                                                     ☐ C II: Processing of perishable vegetable products 
                       ☐ A II: breeding of fish and shellfish*                    ☐ C III: Processing of perishable animal and plant 
                       ☐ B I: Growing of plants (other than grains and            products (mixed products) 
                       pulses)*                                                   ☐ C IV: Processing of stable environment products 
                       ☐ B II: Growing of grains and pulses*                      ☐ G I: Transportation and storage services for 
                       ☐ C I: Processing of perishable animal products            perishable food products and animal feeds 
                       ☐ C II: Processing of perishable vegetable products        ☐ G II: Transportation and storage services for 
                       ☐ C III: Processing of perishable animal and plant         stable environment food products and animal 
                       products (mixed products)                                  feeds 
                       ☐ C IV: Processing of stable environment products          ☐ K: Production of (bio)chemicals 
                       ☐ D I: Production of animal feeds* 
                       ☐ D II: Production of pet feeds* 
                       ☐ E: Catering* 
                       ☐ F I: Retail trade/wholesale* 
                       ☐ F II: Food mediation/trade* 
                       ☐ G I: Transportation and storage services for 
                       perishable food products and animal feeds 
                       ☐ G II: Transportation and storage services for 
                       stable environment food products and animal 
                       feeds 
                       ☐ H: Services* 
                       ☐ I: Production of food packaging and packaging 
                       materials 
                       ☐ J: Manufacture of equipment* 
                       ☐ K: Production of (bio)chemicals 
                    
                    Number of HACCP studies                                                       
                                                                                                  
                    Type/description of HACCP studies 
                    
                    Number of FTE                                                                 
                              © Kiwa                            Version number 04: 04-04-2022                           Page 2 of 3 
                    
                   ISO 22000/FSSC 22000 application form                                                                                         
                                                                                                                                            
                     (in the case of shifts, take the number 
                     from the biggest shift (including seasonal 
                     workers) plus office staff)   
                     Is work carried out in several shifts?          ☐  Yes, number of shifts                                
                                                                     ☐  No 
                     If Yes: name the start times of the shifts.      
                                                                      
                     Are some activities season-dependent?           ☐  Yes 
                                                                     ☐  No   
                     If Yes: name the season and the activity         
                                                                      
                    
                     Number of locations 
                     Are the business activities (to be certified)   ☐  Yes, number:                               
                     spread over several                             ☐  No 
                     locations/subsidiaries?                         If Yes: also answer the following questions. 
                     (purchasing, quality, HR etc. fall under this 
                     too) 
                     Do the locations/subsidiaries belong to         ☐  Yes 
                     the same statutory entity?                      ☐  No 
                                                                     If No: complete the application form for each location 
                                                                     separately 
                     Name, address, FTE and activities for each       
                     location/subsidiary.                             
                     (preferably also send an overview of the         
                     organisational structure)                        
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                    
                    
                    
                                  Thank you for completing the form, please now send it to sales@kiwacmr.nl. 
                              © Kiwa                             Version number 04: 04-04-2022                            Page 3 of 3