A. PROFILE OF COMPANY

Name of Company

Company Registration Number

Correspondence Address

Telephone

Fax

Email

Website

B. ACTIVITIES OF COMPANY

B1. Crop Sector

Activities

Yes/No

Types Of Produce

Location Of  Production Site

Are you a crop producer, with produce sourced from your own farms?

Yes

No

Do you source and collect the produce, through contract farming agreement.

Yes

No

Do you undertake downstream processing of the produce to other products (e.g. juice, etc).

Yes

No

B2. Fishery Sector

Are you involved in the production of fishery produce in fresh, frozen, cooked form, etc (e.g. frozen prawn).

Yes

No

Do you undertake downstream processing of fresh fishery produce (e.g. fish) to other food products (e.g. fish balls).

Yes

No

B3. Livestock Sector

Are you involved in the rearing and production of chickens?

Yes

No

Are you involved in processing of primary livestock produce (e.g. fresh, frozen chicken, drumsticks, etc).

Yes

No

Do you undertake downstream processing of primary fresh livestock produce (chicken) to other food products (e.g. burger, nuggets).

Yes

No

C. SPECIFICATIONS OF PACKED

Identification of Package

(Please Tick)

• Label

• Barcodes

• Others (please specify)

Types of Information Captured on Package (Please list or enclosed copy of labels)

D. MARKETING OF PRODUCTS

Destination

(Please Tick)

North America (Canada, USA, Mexico)

European Union (EU)

Easter

Middle East

South America

Africa

Japan

China, Taiwan and Hong Kong

Australia and New Zealand

South East Asia (Singapore, Indonesia, Thailand, etc)

Malaysia

Other Markets (please specify)

E. QUALITY ASSURANCE SCHEME PRACTICED BY COMPANY

Type

(Please Tick)

Certified By

ISO 9002 - Quality Management System

Good Manufacturing Practice (GMP)

Hazard Analysis Critical Control Point (HACCP)

Farm Certification Scheme of Malaysia (SALM)

Certification to EurepGAP Standard

Good Aquaculture Practice Certification Scheme of Malaysia (SPLAM)

Skim Akreditasi Ladang Ternakan of Malaysia (SALT)

Veterinary Health Mark (VHM) Malaysia

Organic Certification Scheme Malaysia (SOM)

Halal Cerification

Others (please specify)

F. BRIEF DESCRIPTION OF COMPUTER SYSTEM OF COMPANY

Are there computers installed in your company? (Yes or No)

Yes   No

Are records of company's operation computerized? (Yes or No)

Yes   No

Does your company have access to the Internet (Yes or No)

Yes   No

G. COMMITMENT FOR PARTICIPATION

Are you interested and committed to demonstrate food traceability of your products and participate in this project? (Yes or No)

Yes    No

H. NAME AND SIGNATURE OF RESPONDING COMPANY

Name and Seal of Company

Name of Contact Person

Designation

Hand Phone No

Date

 NOTE TO PARTICIPATING COMPANIES

 Please send duly completed form to :

M-FIT Project Office
S08, 2320 Century Square
63000 Cyberjaya
Selangor, Malaysia

Tel No : 03-8318 4113
Fax No :03-8319 6113

For enquiries and further information, please contact :

Kamariah Manap

H/P: 012-688 7117

En. Zuri Mohd Zin
H/P: 019-306 7629