STATUTORY DECLARATION REGISTERED PRODUCTS

Transcription

1 Autralian Certified Organic Pty Ltd ABN STATUTORY DECLARATION REGISTERED PRODUCTS TE: PLEASE RETURN THIS COMPLETED DOCUMENT TO THE ACO OFFICE AT: ADDRESS STATED ABOVE INSTRUCTIONS FOR COMPLETING THIS DOCUMENT Thi Statutory Declaration form the bai of your application for regitration. To avoid any delay, it i important that each ection of thi document i completed accurately. Pleae read the following detail carefully, failure to provide the neceary information will reult in thi document being returned for additional information. To minimie delay with your application pleae enure thi document and any attached information i either typed or printed in black or blue pen CLEARLY in CAPITAL LETTERS. If regitration i required for more than one PRODUCT, on eparate facilitie, title or under eparate management ytem, a Statutory Declaration mut be completed for each FACILITY. ALL QUESTIONS MUST BE ANSWERED: WRITE N/A, NIL OR NE IF T APPLICABLE. Thi document mut be igned on each page and where indicated on Page 15 before a Witne (a pecified in Eligible Witne Lit Page 13-15). Pleae note: family member are ineligible to witne. Within one month of receipt of thi document: An ACO authoried auditor will make an appointment to viit your FACILITY for an evaluation for regitration. Thi firt audit of your operation hould occur within the firt three month from your application unle you have elected for the fat track payment option. Sample/ of PRODUCT may be taken for chemical reidue teting. The auditor report i forwarded to the Certification Review Committee, which analye all factor relating to organic proceing. The applicant will be advied of the outcome of the certification review within 6 week of the firt audit occurring, unle there are mitigating circumtance. THE FOLLOWING CHECKLIST MUST BE COMPLETED PRIOR TO POSTING YOUR APPLICATION. THIS WILL ASSIST IN THE APPRAISAL OF YOUR APPLICATION. CHECKLIST All ection of the Statutory Declaration have either been anwered or marked NA Thi Statutory Declaration ha been initialled and dated at the bottom of every page by the client, in the preence of the witne (a pecified in eligible witne lit Page 13-15) who ha alo initialled and dated the bottom of every page. Pleae note: family member are ineligible to witne. Additionally, the client and witne have printed their name, igned in full and dated thi Statutory Declaration where indicated in the boxed ection. Facilitie layout/floor plan Flow chart of production proce Ingredient lit for all ingredient and aid to be ued Lit of all relevant record heet to be maintained Propoed labelling for regitered product Management Plan pecification for handling and proceing of regitered product. That an area ketch and a written decription giving clear direction from the nearet town to the facility involved i encloed to enable the auditor to viit the property. TICK WHEN COMPLETE Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 28/05/2013] (Page 1 of 14)

2 Autralian Certified Organic Pty Ltd ABN STATUTORY DECLARATION REGISTERED PRODUCTS 1. LICENSEE(S) DETAILS I, BEING THE PERSON RESPONSIBLE FOR THIS DECLARATION (HEREIN REFERRED TO AS THE OPERATOR): Surname Given Name TRADING AS: Trading Name DO SOLEMNLY AND SINCERELY DECLARE: 2. OPERATION DETAILS OPERATION TYPE: (pleae tick) Company Partnerhip Sole Operator Public Company BUSINESS NUMBERS: Trut ABN ABN (If applicable) 3. POSITION DETAILS MY POSITION IS: (pleae tick) Sole Owner Partner Secretary Co-owner Director Shareholder Employee Manager Conultant Sharefarmer 4. SHAREHOLDER / PARTNER DETAILS SHAREHOLDER / PARTNER 1: Other (pleae pecify) Surname Given Name SHAREHOLDER / PARTNER 2: Surname Given Name SHAREHOLDER / PARTNER 3: Surname Given Name SHAREHOLDER / PARTNER 4: Surname Given Name Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 2 of 14)

3 Autralian Certified Organic Pty Ltd ABN CONTACT DETAILS MY CONTACT DETAILS ARE: Telephone (BUS) Telephone (AH) Mobile FAX (BUS) FAX (AH) 6. FACILITY ADDRESS DETAILS POSTAL ADDRESS: Addre Suburb Potcode PHYSICAL ADDRESS: Addre Suburb Potcode 7. BUSINESS ACTIVITIES THAT CORE BUSINESS ACTIVITIES ARE: 8. REGISTRATION TYPE THAT REGISTRATION IS SOUGHT AS AN: (pleae tick) Allowed Input (Agricultural Input) Approved Product (Food/Drink, Health Care Product ONLY) AND THAT THE NAMES OF RELEVANT OTHER PARTIES OR BUSINESSES ASSOCIATED WITH THE HANDLING AND PROCESSING OF PRODUCTS ARE/WILL BE: 9. REGISTRATION / CERTIFICATION ARE YOU CURRENTLY REGISTERED OR CERTIFIED WITH ANY OTHER CERTIFYING BODIES? (pleae tick) (pleae provide detail below) THAT PRODUCT OR PART THEREOF HAS BEEN REFUSED REGISTRATION OR CERTIFICATION WITH ANY ORGANIC ORGANISATION ANYWHERE: (pleae provide detail below) Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 3 of 14)

4 Autralian Certified Organic Pty Ltd ABN PURPOSE OF PRODUCT/S THAT THE INTENDED PURPOSE OF THE PRODUCTS EXPECTED TO BE USED IS: THAT THIS PRODUCT IS TO BE USED AS A FOLIAR FEED: 11. PROCESS DESCRIPTION THAT THE DESCRIPTION OF PROCESSES INVOLVED IN PROCESSING REGISTERED PRODUCT IS: 12. OTHER REGISTERED PRODUCTS THAT THERE ARE PRODUCTS, OTHER THAN BFA REGISTERED PRODUCT HANDLED AND PROCESSED: (pleae tick) (PLEASE PROVIDE DETAILS BELOW) 13. PRODUCT DETAILS THAT THE PRODUCT IS SOLD IN THE FORM OF: PELLETISED GRANULATED FINE POWDER LIQUID OTHER (pleae pecify): THAT IF PELLETISED OR GRANULATED, PLEASE NAME BINDING AGENT: THAT THE ACTION/REACTION OF THE STATED PRODUCT SEEKING REGISTRATION IS: MINERAL BIOLOGICAL CHEMICAL STIMULANT WATER SOLUBLE OTHER (pleae provide detail below): Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 4 of 14)

5 Autralian Certified Organic Pty Ltd ABN THAT A COMPREHENSIVE LIST OF ALL (N REGISTERED) INPUTS, INGREDIENTS, PROCESSING AIDS, ETC EITHER BEING IN THE END PRODUCT OR BEING USED IN THE PRODUCTION PROCESS ARE: THAT AN ANALYSIS OF PRODUCT SHOWING PH, MAJOR AND MIR NUTRIENTS/ ELEMENTS STATUS IS: THAT SYNTHETIC OR NATURAL CHELATING AGENTS ARE USED: (pleae provide detail below) THAT LISTED ARE SOLVENTS, ACID, AND CHEMICALS OF ANY KIND USED IN MANUFACTURE: THAT THE METHOD USED FOR THE EXTRACTION OF NUTRIENTS (IF APPLICABLE) IS: THAT LISTED ARE PRESERVATIVES, ANTIOXIDANTS, STABILISERS USED: THAT LISTED ARE OTHER CHEMICAL ADDITIVES, SURFACTANTS, ETC USED: THAT ALL OTHER ADDITIVES, AGENTS, CATALYSTS AND INGREDIENTS T YET LISTED ARE: Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 5 of 14)

6 Autralian Certified Organic Pty Ltd ABN RAW MATERIALS THAT THE SOURCE OF ALL RAW MATERIAL/S IS: 15. SEPARATION / SEGREGATION THAT REGISTERED PRODUCTS AND OTHER N-CERTIFIED PRODUCTS ARE/WILL BE KEPT SEPARATE/SEGREGATED BY THE FOLLOWING MEANS: (INCLUDING GENETICALLY ENGINEERED PRODUCTS) : 16. RESPONSIBILITY THAT (TITLE AND NAME) TAKES RESPONSIBILITY FOR KEEPING REGISTERED AND N CERTIFIED PRODUCE/PRODUCTS SEPARATE. AND THAT IN THEIR PLACE (TITLE AND NAME) IS SECOND IN CHARGE. 17. EQUIPMENT THAT THE SAME EQUIPMENT IS USED FOR CONTACT WITH AND/OR HANDLING AND PROCESSING OF REGISTERED PRODUCTS AND OTHER N REGISTERED PRODUCTS: (pleae tick) 18. METHODS USED THAT ALL RELEVANT EQUIPMENT HAS UNDERGONE A CLEAN DOWN OF N REGISTERED PRODUCT BEFORE REGISTERED PRODUCTS ARE PROCESSED: (SPECIFY METHOD): 19. RESPONSIBILITY THAT (TITLE AND RESPONSIBILITY) TAKES/HAS RESPONSIBILITY FOR THE CLEANING OF EQUIPMENT, PREPARATION AREAS, ETC. Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 6 of 14)

7 Autralian Certified Organic Pty Ltd ABN CLEANING THAT THE DETAILS AND DESCRIPTION OF RMAL PLANT CLEANING PROCEDURES AND PRODUCTS USED ARE, OR ATTACH A COPY OF CLEANING PROCEDURES: (LIST ALL CHEMICALS, AND PLEASE ENSURE MSDS ARE KEPT ON-SITE) 21. WATER THAT WATER IS ADDED TO THE PRODUCT: (pleae tick) No Ye (pleae provide detail below) SOURCE: THAT THE DETAILS OF WATER, IF USED, FOR CLEANING PURPOSES ARE: SUPPLY: THAT WATER IS FILTERED BEFORE USE: (pleae tick) THAT TYPE OF FILTRATION/PURIFICATION PROCESS USED IS: IT IS TREATED: (pleae tick) No Ye (pleae provide detail below) Detail of treatment: THAT WATER IS RE-CIRCULATED WITHIN THE PLANT: (pleae tick) COMMENTS ON WATER QUALITY: THAT WATER TESTS IS/ARE COMPLETED (COPY ATTACHED): (pleae tick) 22. ANIMAL MANURES THAT ANIMAL MANURES ARE USED: (pleae provide detail below) THAT MANURES ARE COMPOSTED: (pleae provide detail below compoing proce and principle) Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 7 of 14)

8 Autralian Certified Organic Pty Ltd ABN POTENTIAL RISK THAT POTENTIAL AREAS OF RISK ARE: (INCLUDING GMO S, PESTICIDES, ETC) THAT MANAGEMENT STRATEGIES IN PLACE TO ELIMINATE THESE RISKS ARE: THAT (CHEMICAL) RESIDUE TESTS FOR AGRI-CHEMICALS AND/OR HEAVY METALS AND ANY OTHER RELEVANT TESTS HAVE BEEN CARRIED OUT: (pleae provide reult) INGREDIENTS SECTION: COPIES OF ALL CURRENT CERTIFICATION CERTIFICATES FOR ALL SUPPLIERS ARE TO BE KEPT ON FILE. TE: INDIVIDUAL BFA INGREDIENT LIST TO BE COMPLETED FOR EACH PRODUCT TO BE CERTIFIED. 24. IMPORTED PRODUCT THAT THE PRODUCT OR ANY PART THEREOF IS IMPORTED INTO AUSTRALIA: (pleae provide country, region and upplier detail below) THAT IF IMPORTED, HAS THIS PRODUCT RECEIVED REGISTRATION FROM AN ORGANIC CERTIFICATION / REGISTRATION ORGANISATION IN ATHER COUNTRY: (pleae provide detail below) 25. GENETIC ENGINEERING TECHLOGY THAT GMOS DO T CONSTITUTE ANY PART OF THE REGISTERED PRODUCT AND ARE T USED IN THE PRODUCTION PROCESS: (pleae tick) 26. IRRADIATION TECHLOGY THAT IRRADIATION OF INGREDIENTS OR PRODUCTS IS USED DURING MANUFACTURING: (pleae tick) (pleae provide detail below) Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 8 of 14)

9 Autralian Certified Organic Pty Ltd ABN N GMO / N IRRADIATION THAT THE FOLLOWING EXPLAINS HOW N GMO STATUS OF INGREDIENTS AND END PRODUCTS IS ENSURED AND MAINTAINED FOR ALL REGISTERED PRODUCTS (INCLUDE DECLARATIONS FROM SUPPLIERS, ETC WHERE RELEVANT): 28. SUB-STANDARD / REJECTED / WASTE THAT THE FOLLOWING IS REMOVED FROM THE ORIGINAL PRODUCT, OTHER THAN SUB-STANDARD / REJECTED / WASTE PRODUCT: PRODUCT REMOVED % REMOVED 29. PACKAGING 30. TYPES OF PACKAGING THAT THE TYPES OF PACKAGING USED ARE: THE PRODUCT IS PACKAGED FOR RETAIL SALE: (pleae tick) THE PRODUCT IS SOLD FOR BULK SALE: (pleae tick) THE PRODUCT IS SOLD FOR RE-PACKAGING: (pleae tick) 31. TECHNIQUES THAT TECHNIQUES USED FOR PACKAGING USED ARE: 32. HEALTH AND SAFETY Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 9 of 14)

10 Autralian Certified Organic Pty Ltd ABN ENVIRONMENT & SOCIAL WELFARE THAT THE ENVIRONMENTAL IMPACT INVOLVED AS A RESULT OF THE EXTRACTION PROCESSING OR MANUFACTURING OF THESE PRODUCT ARE: THAT SOCIAL WELFARE ISSUES RELATING TO THE EXTRACTING ETC OF THIS PRODUCT ARE: 34. STORAGE AND DISTRIBUTION 35. CONTAMINATION PREVENTION THAT WHILE GOODS ARE BEING TRANSPORTED, CONTAMINATION OR MIXING OF PRODUCTS IS PREVENTED BY: 36. TRANSPORTATION THAT TRANSPORTATION FOR INCOMING AND OUTGOING GOODS ARE (TYPE AND NAME/S): 37. PESTS 38. PEST MANAGEMENT THAT PESTS (INSECTS, RODENTS, ETC) ARE MANAGED BY: 39. PEST CONTROL TREATMENTS THAT PREMISES ARE SUBJECTED TO PEST CONTROL TREATMENTS: (pleae tick) (pleae provide detail below) (Pleae pecify) Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 10 of 14)

11 Autralian Certified Organic Pty Ltd ABN TE: PROVIDE A FULL LIST OF ALL CHEMICALS USED. (MSDS SHEETS ARE TO BE KEPT ON FILE): 40. WEEDS FOR LAND BASED PRODUCTION PREMISES ONLY THAT WEEDS ARE CONTROLLED AROUND THE PREMISES BY: 41. ADDITIONAL PRACTICES THAT ANY OTHER CHEMICALS, TREATMENTS OR OTHER ADDITIONS OR PRACTICES ARE USED WHICH HAVE T YET BEEN SPECIFIED: (pleae tick) (Pleae pecify) (pleae provide detail below) 42. RECORDS THAT MAINTAINING AUDITABLE RECORDS OF ALL KEY ELEMENTS OF THE PRODUCTION PROCESS, AND OF INCOMING AND OUTGOING REGISTERED GOODS IS ESSENTIAL FOR MAINTENANCE OF REGISTRATION. 43. FURTHER COMMENTS THAT FURTHER COMMENTS ARE: 44. TIFICATION THAT ANY DEPARTURE FORM THE REQUIREMENTS SPECIFIED BY THE CURRENT BIOLOGICAL FARMERS OF AUSTRALIA FOR REGISTERED PRODUCTION, PROCESSING AND MARKETING MUST BE TIFIED TO THE BFA IN WRITING AS THIS OCCURS. 45. DECLARATION A. I UNDERSTAND THAT REGULAR SAMPLES OF MY/OUR PRODUCT WILL BE SUBJECT TO A RANDOM CHEMICAL RESIDUE TEST AND COULD BE AT MY OWN EXPENSE WHERE IT CANT BE VERIFIED THAT CONTAMINATION DID T OTHERWISE ARISE FROM ON-SITE PRACTICES: (pleae tick) B. I HAVE READ AND UNDERSTOOD THE CURRENT BIOLOGICAL FARMERS OF AUSTRALIA LTD ORGANIC STANDARD: (pleae tick) Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 11 of 14)

12 Autralian Certified Organic Pty Ltd ABN C. I ACKWLEDGE THIS DECLARATION IS MADE WITH A CLEAR UNDERSTANDING OF THE REQUIREMENTS SET OUT IN THE CURRENT BFA ORGANIC STANDARD: (pleae tick) D. I ACKWLEDGE THAT KEEPING COMPREHENSIVE RECORDS OF PRODUCTION ACTIVITIES AND SALES, AS SPECIFIED IN THE BFA STANDARD, IS A KEY ASPECT OF ATTAINING AND MAINTAINING REGISTRATION: (pleae tick) E. I ACKWLEDGE THAT ANY DEPARTURE FROM THE PRINCIPLES OF THE BFA, AS OUTLINED IN THE ORGANIC STANDARD, MUST BE TIFIED IN WRITING TO THE BFA OFFICE: (pleae tick) F. I/WE ARE AWARE I/WE WILL BE LIABLE FOR PENALTIES APPLICABLE TO THE RELEVANT STATE FOR ANY WILFULLY MADE FALSE STATEMENT: (pleae tick) G. I DO SINCERELY DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE TRUE AND CORRECT TO THE BEST OF MY KWLEDGE AND BELIEF: (pleae tick) H. I HAVE READ AND UNDERSTOOD THE CURRENT VERSION OF THE BIOLOGICAL FARMERS OF AUSTRALIA CO- OP LTD STANDARD HEREIN REFERRED TO AS "THE AUSTRALIAN CERTIFIED ORGANIC STANDARD", WHICH IS ADMINISTERED BY ACO AND WILL COMPLY WITH ALL RELEVANT PROVISIONS OF THE CERTIFICATION PROGRAMS: (PLEASE TICK) No Ye SIGNED: Print Full Name Clearly Signature Date WITNESSED BY: Print Full Name Clearly Signature Date ELIGIBLE WITNESS CATEGORY (Page 13-15) Pleae tate profeion ALL PAGES MUST BE SIGNED, DATED AND WITNESSED (BY AUTHORISED WITNESS LIST BELOW), OTHERWISE DOCUMENT WILL BE RETURNED. Family member are ineligible to witne documentation. The following lit detail people that are able to witne a tat dec under the Statutory Declaration Regulation of 1993 which i bound by the Statutory Declaration Act of 1953 under Autralian Commonwealth Law (doe not differ to individual tate) A tatutory declaration under the Statutory Declaration Act 1959 may be made before (1) a peron who i currently licened or regitered under a law to practie in one of the following occupation: The following lit detail people that are able to witne a tat dec under the Statutory Declaration Regulation of 1993 which i bound by the Statutory Declaration Act of 1953 under Autralian Commonwealth Law (doe not differ to individual tate) A tatutory declaration under the Statutory Declaration Act 1959 may be made before (1) a peron who i currently licened or regitered under a law to practie in one of the following occupation: Chiropractor Dentit Legal practitioner Medical practitioner Nure Optometrit Patent attorney Pharmacit Phyiotherapit Pychologit Trade mark attorney Veterinary urgeon (2) a peron who i enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Autralia, a a legal practitioner (however decribed); or Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 12 of 14)

13 Autralian Certified Organic Pty Ltd ABN (3) a peron who i in the following lit: Agent of the Autralian Potal Corporation who i in charge of an office upplying potal ervice to the public Autralian Conular Officer or Autralian Diplomatic Officer (within the meaning of the Conular Fee Act 1955) Bailiff Bank officer with 5 or more continuou year of ervice Barriter Building ociety officer with 5 or more year of continuou ervice Chief executive officer of a Commonwealth court Clerk of a court Commiioner for Affidavit Credit union officer with 5 or more year of continuou ervice Employee of the Autralian Trade Commiion who i: (a) in a country or place outide Autralia; and (b) authoried under paragraph 3 (d) of the Conular Fee Act 1955; and (c) exerciing hi or her function in that place Employee of the Commonwealth who i: (a) in a country or place outide Autralia; and (b) authoried under paragraph 3 (c) of the Conular Fee Act 1955; and (c) exerciing hi or her function in that place Fellow of the National Tax Accountant Aociation Finance company officer with 5 or more year of continuou ervice Holder of a tatutory office not pecified in another item in thi lit Judge of a court Jutice of the Peace Jutice of the Peace (Commiioner for Declaration) Magitrate Marriage celebrant regitered under Subdiviion C of Diviion 1 of Part IV of the Marriage Act 1961 Mater of a court Member of Chartered Secretarie Autralia Member of Engineer Autralia, other than at the grade of tudent Member of the Aociation of Taxation and Management Accountant Member of the Autralaian Intitute of Mining and Metallurgy Member of the Autralian Defence Force who i: (a) an officer; or (b) a non-commiioned officer within the meaning of the Defence Force Dicipline Act 1982 with 5 or more year of continuou ervice; or (c) a warrant officer within the meaning of that Act Member of the Intitute of Chartered Accountant in Autralia, the Autralian Society of Certified Practiing Accountant or the National Intitute of Accountant Member of: (a) the Parliament of the Commonwealth; or (b) the Parliament of a State; or (c) a Territory legilature; or (d) a local government authority of a State or Territory Miniter of religion regitered under Subdiviion A of Diviion 1 of Part IV of the Marriage Act 1961 Notary public Permanent employee of the Autralian Potal Corporation with 5 or more year of continuou ervice who i employed in an office upplying potal ervice to the public Permanent employee of: (a) the Commonwealth or a Commonwealth authority; or (b) a State or Territory or a State or Territory authority; or (c) a local government authority; with 5 or more year of continuou ervice who i not pecified in another item in thi lit Peron before whom a tatutory declaration may be made under the law of the State or Territory in which the declaration i made Police officer Regitrar, or Deputy Regitrar, of a court Senior Executive Service employee of: (a) the Commonwealth or a Commonwealth authority; or Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 13 of 14)

14 Autralian Certified Organic Pty Ltd ABN (b) a State or Territory or a State or Territory authority Sheriff Sheriff officer Solicitor Teacher employed on a full-time bai at a chool or tertiary education intitution Form Iue 1 Reviion 3 [APPROVED BY: Michael Baker 04/112013] (Page 14 of 14)