Year.……. month……. date……
Request for the scope of certification for manufacturer To Director of PT. Mutuagung Lestari
Applicant name Head Office Address
We, under the provision of Article 19-3 paragraph 1 of the law concerning Standardization and Proper Labeling of Agricultural and Forestry Products (Law No. 175 in 1950) hereby, make a request for the scope of certification as follows because we intent to obtain a certification as to what we indicate the grading.
1. The denomination, the address and responsible person’s
name of the
manufacturing plant
Factory name : Factory address :
Responsible
person :
Position :
3. The name of contact person who takes charge of the certification
Name :
Position :
Email :
Phone number : 5. The kinds and
classification of the agricultural and forestry products
intended for
obtaining the
certification
Category : Glued Laminated Timber (GLT) Item product : Please tick the box by double click
& select checked Glued laminated timber for fixtures Glued laminated timber for fixtures, low formaldehyde emission
Decorative glued laminated timber for fixtures Decorative glued laminated timber for post Note: the detail of item products can be seen in the attachment below
9. The estimated
quantity of output and the estimated volume of graded products and the estimated volume of products indicated the grading 1 year, after the submission of such certification
Item
The estimated quantity of output in 1
year
The estimated volume of
exported products in 1
year
The estimated volume of JAS graded products
in 1 year
10. How to get the mill by transport
11. Our office mailing address
Address :
Person in
charge :
Email :
Phone
number :
15. Our office address for invoice delivery
Address :
Person in
charge :
Email :
Phone
number :
19. Legal business license
Company Registration / Tanda Daftar Perusahaan (TDP) /
Nomor Induk Bersama (NIB) Nomor Pokok Wajib Pajak (NPWP) Others:………
20. Purpose of certification
New Application / Factory Additional item products Additional resin/wood species Others:
Detail of the scope of certification
Name of Factory:Category Item product Detail of the scope
Check list for the reference
1. Facility of Manufacturing, Storage and Quality Control
Item Judgem
ent Note
Manufacturing facility
Storage facility Quality Control facility
2. Organization and implementation method of Quality Control (QC)
Item Judgem
ent
Note Criteria for QC
Implementation of QC
Result of QC
3. Qualification and the number of persons in charge of Quality Management (QM)
Item Judgem
ent Note
Persons in charge of
QM Number of persons : (Qualification :
Have / Not have) Responsible person
in QM Number of persons : (Qualification : Have / Not have)
Persons in charge surface quality inspection
Number of persons : (Qualification : Have / Not have)
4. Organization and Implementation methods of grading
Item Judgem
ent Note
Organization of grading
Implementation method of grading Organization that entrust the test for grading
Organization :
Agreement of entrusting : PT Mutuagung Lestari
5. Qualification and the number of persons in charge of grading
Item Judgem
ent Note
Person in charge of
grading Number of persons : (Qualification : Have / Not have)
Note :
In check list forth reference, would judge your self by “Technical Criteria for certification of Manufacturers”.
Declaration
We have read the ROCB “Code of Practice for the Certification” and We agree to fulfill ROCB Certification requirement based on Code of Practice for the Certification.
Nam
e : Signature: Date:
Positi
on :
ROCB office use only
1. Scope of certification : Available Not available 2. Competence and
capability to perform the certification activity :
Available Not available
3. Tools for certification
services : Have Not have
4. Differences of
Understanding between
ROCB and client :
Have Not have
5. Refer to point 4, if there is any differences, please inform the status
:
Finished Not finished
6. Conflict of interest and
impartiality : Have Not have
Reviewed
by : Signature:
Date :
Decision : Continue Not Continue
Reason:
Details of “Glued Laminated Timber”
To PT Mutuagung Lestari
Name of factory: ………. New application Additional item product Additional wood / resin (select one)
No Classification Emission class
Usage (only for GLT
for Fixtures)
Kind of resin
Wood species
Decorative processing (if the Factory apply
it)
Kind of resin for decorative veneer
bonded
Thickness range Finger Joint Butt joint (mm)
1 GLT for Fixtures Decorative GLT for Fixtures
Decorative GLT for Post
F☆☆☆☆
F☆☆☆
Finished Unfinished
PVAc PI
Others:……
Brand: ………..
Supplier: ……..
PVAc PI
Others:……
Brand: ………..
Supplier: ……..
No use Coated Veneer Thickness:
………..
Species:
…………...
N/A PVAc PI
Others:……
Brand: ……….
Supplier: ……….
Thinnest: ………….
Medium: …………..
Thickest: …………..
2 GLT for Fixtures Decorative GLT for Fixtures
Decorative GLT for Post
F☆☆☆☆
F☆☆☆
Finished Unfinished
PVAc PI Others:
Brand: ………..
Supplier: ……..
PVAc PI Others:
Brand: ………..
Supplier: ……..
No use Coated Veneer Thickness:
………..
Species:
…………...
N/A PVAc PI
Others:……
Brand: ……….
Supplier: ……….
Thinnest: ………….
Medium: …………..
Thickest: …………..
Note: please select and tick the box by double click and select “checked”
Usage Kind of resin Wood species, examples:
Finished : GLT for fixtures on which sawing or face adjustment
is worked into dimensionally finished products Un-finsihed: GLT without dimensional finishing
1. PVAc: Poly Vinyl Acetate 2. PI: Polymer Isocyanate
Rubberwood, Pine, Keruing, Meranti, Pulai, Jelutung, etc