F.5.1.2.3. Formulir Pendaftaran Sertifikasi Organik_E1.4 23102014
FORMULIR PENDAFTARAN SERTIFIKASI ORGANIK ORGANIC CERTIFICATION REGISTRATION FORM A. Data Pemohon - Applicant data 1
Nama pemohon Applicant's name
2
Alamat Address
Phone Fax Email 3
Penghubung sertifikasi Contact person for certification
Jabatan Position
Phone Fax Email 4
Tipe pemohon Type of applicant
Perusahaan atau kemitraan Company or Partnership
Kelompok produsen Producer Group
Produsen tunggal Single producer
Kelompok Tani Farmers Group
Manufaktur
Lainnya, sebutkan
Manufacturer
Other (specify):
B. Produk yang disertifikasi & layanan keterangan kepatuhan - Product to be certified & attestation of compliance service
No
Produksi yang disertifikasi Certified operation
Produk/layanan yang diminta untuk sertifikasi Products/services requested for certification
1
Tujuan pasar
Standar
Market destination
Standard
Nasional EU Canada/US Lainnya:
Produksi tanaman: tanaman pangan, perkebunan, rempah-rempah, herbal, atsiri Plant production: cash crops, plantation, spices, herbs, essential oil production
PT BIOCert Indonesia Jl. Perdana Raya Budi Agung Cimanggu Residence Ruko A1 Bogor-16165 INDONESIA Phone: +62 251 5680 496 - 755 1811 Fax: +62 251 755 1811 Email:
[email protected] website: www.biocert.or.id
Keterang an Remark
Standar Pertanian Organik BIOCert [SNI 6729-2013 dan Standar Aliansi Organis Indonesia [Oktober 2011]] BIOCert-EU Equivalence [BIOCert Organic Standard EU Equivalence] BIOCert-COR/NOP Equivalence [CAN/CGSB 32-310 Canada and US] ACT-EU Equivalence [ACT Organic Standard - EU Equivalence], ACT-COR/NOP Equivalence
F.5.1.2.3. Formulir Pendaftaran Sertifikasi Organik_E1.4 23102014
No
Produksi yang disertifikasi Certified operation
Produk/layanan yang diminta untuk sertifikasi Products/services requested for certification
2
Standard
Nasional EU Canada/US Lainnya:
Produksi jamur/kecambah Mushroom/sprout production
4
Standar
Market destination
Nasional EU Canada/US Lainnya:
Produksi ternak dan hasil ternak Livestock and livestock production
3
Tujuan pasar
Nasional EU Canada/US Lainnya:
Produksi apiari (Lebah Madu) Apiary production (Honey bee)
PT BIOCert Indonesia Jl. Perdana Raya Budi Agung Cimanggu Residence Ruko A1 Bogor-16165 INDONESIA Phone: +62 251 5680 496 - 755 1811 Fax: +62 251 755 1811 Email:
[email protected] website: www.biocert.or.id
Keterang an Remark
[CAN/CGSB 32-310 – Canada and US] Others: Standar Pertanian Organik BIOCert [SNI 6729-2013 dan Standar Aliansi Organis Indonesia [Oktober 2011]] BIOCert-EU Equivalence [BIOCert Organic Standard EU Equivalence] BIOCert-COR/NOP Equivalence [CAN/CGSB 32-310 Canada and US] ACT-EU Equivalence [ACT Organic Standard - EU Equivalence], ACT-COR/NOP Equivalence [CAN/CGSB 32-310 – Canada and US] Others: Standar Pertanian Organik BIOCert [SNI 6729-2013 dan Standar Aliansi Organis Indonesia [Oktober 2011]] BIOCert-EU Equivalence [BIOCert Organic Standard EU Equivalence] BIOCert-COR/NOP Equivalence [CAN/CGSB 32-310 Canada and US] ACT-EU Equivalence [ACT Organic Standard - EU Equivalence], ACT-COR/NOP Equivalence [CAN/CGSB 32-310 – Canada and US] Others: Standar Pertanian Organik BIOCert [SNI 6729-2013 dan Standar Aliansi Organis Indonesia [Oktober 2011]] BIOCert-EU Equivalence [BIOCert Organic Standard EU Equivalence] BIOCert-COR/NOP Equivalence [CAN/CGSB 32-310 Canada and US] ACT-EU Equivalence [ACT Organic
F.5.1.2.3. Formulir Pendaftaran Sertifikasi Organik_E1.4 23102014
No
Produksi yang disertifikasi Certified operation
Produk/layanan yang diminta untuk sertifikasi Products/services requested for certification
5
7
Standar
Market destination
Standard
Nasional EU Canada/US Lainnya:
Pengumpulan/pemanenan produk liar Wild collection/harvesting
6
Tujuan pasar
Grower group
Nasional EU Canada/US Lainnya:
Pengolahan produk tanaman, ternak dan hasil ternak, produk liar, produk khusus [jamur/kecambah, apiari]
Nasional EU Canada/US Lainnya:
Kelompok produsen
Processing for plant product, livestok and livestock production, wild product, special product [mushroom/sprout, apiary]
PT BIOCert Indonesia Jl. Perdana Raya Budi Agung Cimanggu Residence Ruko A1 Bogor-16165 INDONESIA Phone: +62 251 5680 496 - 755 1811 Fax: +62 251 755 1811 Email:
[email protected] website: www.biocert.or.id
Keterang an Remark
Standard - EU Equivalence], ACT-COR/NOP Equivalence [CAN/CGSB 32-310 – Canada and US] Others: Standar Pertanian Organik BIOCert [SNI 6729-2013 dan Standar Aliansi Organis Indonesia [Oktober 2011]] BIOCert-EU Equivalence [BIOCert Organic Standard EU Equivalence] BIOCert-COR/NOP Equivalence [CAN/CGSB 32-310 Canada and US] ACT-EU Equivalence [ACT Organic Standard - EU Equivalence], ACT-COR/NOP Equivalence [CAN/CGSB 32-310 – Canada and US] Others: Standar Pertanian Organik BIOCert [SNI 6729-2013 dan Standar Aliansi Organis Indonesia [Oktober 2011]] BIOCert-EU Equivalence [BIOCert Organic Standard EU Equivalence] BIOCert-COR/NOP Equivalence [CAN/CGSB 32-310 Canada and US] ACT-EU Equivalence [ACT Organic Standard - EU Equivalence], ACT-COR/NOP Equivalence [CAN/CGSB 32-310 – Canada and US] Others: Standar Pertanian Organik BIOCert [SNI 6729-2013 dan Standar Aliansi Organis Indonesia [Oktober 2011]] BIOCert-EU Equivalence [BIOCert Organic Standard EU Equivalence] BIOCert-COR/NOP Equivalence
F.5.1.2.3. Formulir Pendaftaran Sertifikasi Organik_E1.4 23102014
No
Produksi yang disertifikasi Certified operation
Produk/layanan yang diminta untuk sertifikasi Products/services requested for certification
Tujuan pasar
Standar
Market destination
Standard
Keterang an Remark
[CAN/CGSB 32-310 Canada and US] ACT-EU Equivalence [ACT Organic Standard - EU Equivalence], ACT-COR/NOP Equivalence [CAN/CGSB 32-310 – Canada and US] Others:
8
Impor produk organik
Indonesia
SNI 6729-2013
Importing organic product
9
Keterangan Kepatuhan
BIOCert-COR/NOP Equivalence [CAN/CGSB 32-310 Canada and US]
Canada
Attestation of Compliance
10
Input organik
Indonesia
SNI 6729-2013
Organic inputs
Catatan: apabila mengajukan sertifikasi untuk ekspor, pemohon secara otomatis turut serta dalam program sertifikasi organik nasional. Note: if you apply for export certification, you will follow national certification program authomatically.
Bila B.7 berlaku untuk pengolahan produk organik, mohon pilih tipe pengolahan yang dilakukan. If B.7 is applicable for organic processing, please select type of processing unit done.
1. 2. 3.
Kontrak pengolahan - Contract processing Pengolahan sendiri - Self processing Pengolahan sederhana [ingredien tunggal dengan tanpa produksi paralel] - Simple processing (mono-ingredient with no parallel processing)
Bila B.9 berlaku untuk keterangan kepatuhan, mohon pilih tipe layanan yang dilakukan (berlaku untuk nomor 8-12) . If B.9 is applicable for organic processing, please select type of processing unit done.
4.
Pengolahan sederhana tapi paralel- Simple processing
but
parallel
5.
Pengolahan komplek [multi ingredien tanpa pengolahan paralel] - Complex processing (multi-ingredients without parallel processing)
6.
Pengolahan komplek [dengan pengolahan paralel]Complex processing (with parallel processing)
7. 8.
Pengemasan ulang - Re-packing Pemotongan ternak - Livestock slaughtering
9.
Kontrak penyimpanan - Contract storage
10. 11. 12.
Pembersihan benih – Seed Cleaning Transportasi produk – Product transportation Lainnya - others : ........................
PT BIOCert Indonesia Jl. Perdana Raya Budi Agung Cimanggu Residence Ruko A1 Bogor-16165 INDONESIA Phone: +62 251 5680 496 - 755 1811 Fax: +62 251 755 1811 Email:
[email protected] website: www.biocert.or.id
F.5.1.2.3. Formulir Pendaftaran Sertifikasi Organik_E1.4 23102014
C. Lokasi Produksi - Location of production 1
Lokasi kebun
2
Alamat fasilitas pengolahan, pengemasan dan gudang, termasuk fasilitas yang disubkontrak. Mohon dituliskan secara lengkap apabila memiliki lebih dari satu lokasi usaha (seperti nama kecamatan dan kota)
Location of farm
Address of processing, packing and warehouse facilities Please write completely if has more than one production site (example write name of sub district or town)
3
Luas area [ha] Harap diisi hanya area yang disertifikasi saja.
------------ ha Berlaku untuk B.6
Total area [ha] Please write for certified area only
Applicable for B.6
Jumlah petani Number of farmers
Jumlah kebun Number of farms
4
------- Petani - Farmers -------- Kebun - Farms
Petunjuk mencapai lahan Anda. Mohon tunjukkan jarak dan waktu yang diperlukan untuk mencapai lahan Anda dari Bogor-Jawa Barat: Direction to reach your farm/manufacture. Please indicate distance and time required to reach your farm/manufacture from Bogor-West Java:
Waktu yang Anda kehendaki untuk dilakukan inspeksi (tanggal/bulan/tahun): When will you be inspected (date/month/year)
Untuk pengaturan inspeksi, konfirmasi hal-hal
mohon berikut:
Transportasi
Akomodasi
Makan
Transportation
Accommodation
Meals
For inspection arrangement, please confirm the following issues:
Nama pemohon Name of the Applicant
Tandatangan Signature
Tanggal Date
PT BIOCert Indonesia Jl. Perdana Raya Budi Agung Cimanggu Residence Ruko A1 Bogor-16165 INDONESIA Phone: +62 251 5680 496 - 755 1811 Fax: +62 251 755 1811 Email:
[email protected] website: www.biocert.or.id
F.5.1.2.3. Formulir Pendaftaran Sertifikasi Organik_E1.4 23102014
Rev
Deskripsi Perubahan
0
1
2
3 4
Notes : dokumen telah ada sebelumnya namun belum memiliki nomor dokumen. Revisi standar SNI dan menambahkan opsi “BIOCertEU” dan “BIOCert-COR” Revisi standar BIOCert-EU equivalence dan BIOCert-COR. Menambahkan opsi : sertifikasi kelompok. Perubahan format Menambahkan tipe pengolahan Menambahkan lokasi kebun dan unit pengolahan, pengemasan, penyimpanan Menambahkan layanan attestation of compliance Menambahkan layanan input organik
Riwayat Revisi Diubah Oleh Posisi/ Dept
Tanggal Efektif
Status
HSM
CS
13112013
Tidak terpakai
PSR
QM
01042014
Tidak terpakai
PSR, ATT
QM
22072014
Terpakai
PSR
QM
22082014
Tidak terpakai
PSR
QM`
23102014
Terpakai
PT BIOCert Indonesia Jl. Perdana Raya Budi Agung Cimanggu Residence Ruko A1 Bogor-16165 INDONESIA Phone: +62 251 5680 496 - 755 1811 Fax: +62 251 755 1811 Email:
[email protected] website: www.biocert.or.id
