Please fill out all data completely and correctly. The information contained on this form will be considered in the certification process proposed. Information submitted in this form will be treated as confidential information.
DATA
1. APLICANT DATA
1.1 RESPONSIBLE PERSON
1.1.1. Full Name of Director
The name of the director will be written in the certificate, filled it as on the certificate of
incorporation. If not, please attach letter of responsible appointment from company or similar letter.
1.1.2. Full Address 1.1.3. Phone 1.1.4. Fax 1.1.5. HP
1.1.6. E-mail Address 1.1.7. Nationality
1.2. MR /QUALITY MANAJEMEN SYSTEM COORDINATOR
1.2.1. Full Name 1.2.2. Phone 1.2.3. Fax 1.2.4. HP
1.2.5. E-mail Address
1.3. CONTACT PERSON
1.3.1. Full Name
1.3.2. Position in Applicant Company
1.3.3. Phone 1.3.4. Fax 1.3.5. HP
1.3.6. E-mail Address
1.4. CORRESPONDENT
1.4.1. To (name)
1.4.2. Position in the company 1.4.3. Full Address
1.4.4. Phone 1.4.5. Fax
1.4.6. E-mail Address
1.5. LEGAL COMPANY
Incorporation
will be written in the product certificate
1.5.2. Form of legal entity
1.6. OFFICE
1.6.1. Full Address
will be written in the product certificate
1.6.2. District/City 1.6.3. Province 1.6.4. Phone 1.6.5. Fax
1.6.6. E-mail Address 1.6.7. Website
1.7. FACTORY
1.7.1. Full Address
will be written in the product certificate
1.7.2. District/City 1.7.3. Province 1.7.4. Phone 1.7.5. Fax
1.7.6. E-mail Address
1A. RESPONSIBLE COMPANY IN INDONESIA (for imported product only)
Only for imported products, filled with the responsible of the products traded in Indonesia
1A.1. RESPONSIBLE COMPANY
1A.1.1. Company Name
Filled with the company name in accordance with the certificate of incorporation, will be written in the certificate
1A.1.2. Full Name of Director
Filled with the company name in accordance with the certificate of incorporation
1A.1.3. Company Full Address
will be written in the certificate
1A.1.4. Phone 1A.1.5. Fax 1A.1.6. HP
1A.1.7. E-mail Address
1A.2. CONTACT PERSON
1A.2.2. Position in the company
1A.2.3. Phone 1A.2.4. Fax 1A.2.5. HP
1A.2.6. E-mail Address
1.B. CORRESPONDENCE
1.B.1. To (name)
1.B.2. Position in the company 1.B.3. Full Address
1.B.4. Phone 1.B.5. Fax
1.B.6. E-mail Address
2. PRODUCT
Use addition technical spesification form for some products (if any)
2.1. Standard number and title 1. 2. 2.3. Product Types 1.
(when the type / types are not sufficient
on this form, it can be attached on a separate sheet)
3. PRODUCTION
3.1. Total production line related to application 3.2. Total shift per day
3.3. Total working hours per shift
3.4. Production capacity per day
If product more than one, please specify for each product
4. ORGANIZATIONAL STRUCTURE
Described your organizational structure
Division Name Responsibility and authority
5. MANPOWER
5.1. Total manpower
Related to application
5.2 Total manpower in production dept.
Related to product applied
5.3. Total manpower in quality dept.
Related to product applied
5.4. Total manpower not in production and quality dept.
6. SUBCONTRACT PROCESS (if any) 6.1. Total subcontract process
6.2. Percentage of subcontract process
6.3. Process to be subcontract
6.4. Subcontract Company Name
6.5. Subcontract Company Address
7. QUALITY MANAGEMENT SYSTEM (QMS)
SNI ISO 9001:2008 certificate QMS Certificate Issuer Validity Periode
Acrediatation Logo KAN IAF Not All SNI ISO 9001:2008 no certificate
Others
8. COMMUNICATION
8.1. Language being used in the factory
8.2. The ability to provide translators for each audit team, if English or
Indonesian could not be used
Yes No
9. DISTANCE, TRAVEL TIME AND CONVEYANCES
From BSI Office to the factory
9.1. JABODETABEK
9.1.1. Distance to Destination (km)
9.1.2. Travel time (hours) 9.1.3. Conveyances
Company vehicle / shuttle, taxi or other. Describe clearly
9.2. OUTSIDE JABODETABEK
9.2.1. Trip - 1
BSI – Soekarno Hatta Airport
BSI – Railways Station or BSI – Bus Terminal or BSI – Shuttle Bus
Taxi
9.2.2. Trip - 2
In accordance with a
conveyance that is used in point 9.2.1
Airplane Hours
9.2.3. Trip - 3
From the arrival point 9.2.2. to hotel
Hours
9.2.4. Trip - 4
From hotel to factory kmhours minutes
9.2.5. Total trip from 9.2.2. to 9.2.3.
9.3. OVERSEAS
9.3.1. Trip - I
LSPro – Soekarno Hatta Airport
Taxi
9.3.2. Trip - 2
By plane, describe in detail the transit, final destination and duration of the trip
Example:
-Jakarta-Singapura, 1 hour 30 minutes
-Singapura, transit 45 minutes
-Singapura-Guangzhou, 4,5 hours
9.3.3. Trip - 3
From hotel to factory. Describe means of transportation,
distance to destination (km) and travel time (minutes)
km
hours minutes
9.3.4. Trip - 4
From hotel to factory. Describe means of transportation,
distance to destination (km) and travel time (minutes)
km
hours minutes
9.3.5. Total trip from 9.3.2. to
9.3.3. hours minutes
10. SNI CERTIFICATE OWNERSHIP FROM OTHER INSTITUTE
10.1. Do you have SNI certificate from other Product
Certification Body (not BSI) in Indonesia?
Yes No
If Yes,
10.2 Name of Institute that issued SNI certificate
10.3 SNI Certificate number dan validity periode
11. JENIS INDUSTRI
Production system By order Continuosly If by order, please attach
production plan for one year for new certificatio and every early year
The above statement was made in good faith
Position
KAJIAN PERMOHONAN Hanya diisi oleh petugas BSI For BSI peronel only
ID :
Nama Perusahaan : 1. Sistem sertifikasi
1 5 lain-lain : 2. Jenis permohonan
SPPT SNI SPPT ST lain-lain : 3. Skema sertifikasi
Ada Tidak Ada 4. Status lingkup akreditasi produk
Penunjukan KAN Non KAN 5. Status penerapan standar
Wajib Sukarela
6. Status Lembaga Sertifikasi Sistem Mutu perusahaan, berlogo : KAN IAF Bukan ketiganya
7. Ketersediaan standar yang dimohon Ada Tidak Ada
8. Ketersediaan Peraturan Pemerintah (untuk produk wajib)
Peraturan Menteri Pemberlakuan Wajib Ada Tidak Ada
Peraturan Menteri Penunjukan LPK Ada Tidak Ada Petunjuk Teknis
Ada Tidak Ada
9. Ketersediaan auditor yang kompeten Ada Tidak Ada
10. Diperlukan tenaga ahli? Ya Tidak
Jika diperlukan, ketersediaan tenaga ahli Ada Tidak Ada
11. Ketersediaan PPC
Ada Tidak Ada 12. Ketersediaan laboratorium
Ada (nama laboratorium) :
Tidak Ada
Status laboratorium
Akreditasi Penunjukan Evaluasi 13. Diperlukan witness?
Ya Tidak
Ketersediaan tenaga ahli laboratorium Ada Tidak Ada
14. Diperlukan perdiem fee? Ya Tidak Jumlah perdiem fee (hari)
hari per orang
16.Jumlah Sertifikat yang dicetak (bila ada permintaan dari pemohon)
Kajian Permohonan I
Tanggal periksa :
Kesimpulan :
terima diperbaiki tidak diterima Alasan bila tidak diterima :
Nama auditor pemeriksa: Mengetahui pihak pemohon, Nama dan Jabatan:
Tanda tangan auditor pemeriksa: Tanda Tangan;
Kajian Permohonan II (bila pada kajian permohonan I dinyatakan diperbaiki)
Tanggal periksa : Kesimpulan :
terima tidak diterima Alasan bila tidak diterima :
Nama auditor pemeriksa: Mengetahui pihak pemohon, Nama dan Jabatan:
Tanda tangan auditor pemeriksa: Tanda Tangan:
Disetujui olehKepala Seksi Operasional Sertifikasi (atau manajemen yang mewakili)
