G

E

N

E

R

A

L

Name of the Organisation

Legal Status

Industry  Classification

Whether  part of  large  group. It  so, please  state group’s  name

Address ( Mailing)

Address  (Site)

Management Representative

Telephone / Fax / e-mail

Tel:

Fax:

e-mail:

S

I

T

E

S

Location

    Site 1

 Site 2

No.Employees:Permanent /Temporary/Contract / Seasonal

No. of  Shifts

Area:

Products  / Services 

Core Processes

Support Processes

S

Y

S

T

E

M

Will any  processe/s  or element/sbe excluded from the Certification Scope?

Yes  / No

If yes,  name

Justification  for  Exclusion :

Legal Obligations

Desired Scope of  Certification

Do you have a System Manual?

Yes

Number of Procedures

System  Implemented  from :

Has a full Internal Audit  been done?

Has a Management

Review been held

Approximate dates  for

Document Review

 Stage 1 Audit :

Stage 2 Audit :

Consultant, if any, engaged  for  system  development / implementation / internal  audit /training.

If  previously  certified, please  enclose  copy of   certificate.

Reasons for  seeking  change  of  CB

Place :

Date  :                                                                                           Signature of  Client  (CEO / MR)

NB : For Multisite certification application, information relating to sites  and system  should be provided separately for each site in this format.

F

O

R

Q

S

I

U

S

E

Within  Scope:

Yes /No

Resources                                Available   /  Not  available

Technical    Area 

IAF           

NACE

Conflict of Interest

Mitigation

Auditor  Days

Certification : Stage 1

Stage 2

Surveillance : 

Reference No. allotted:

Completed by:    

C.B  Approval :

Signature :

Date:

    Signature :

Date: