Application for

System Certification

SUCOFINDO INTERNATIONAL
CERTIFICATION SERVICES
SUCOFINDO a Strategic Business Unit of PT. SUCOFINDO (PERSERO)

SUCOFINDO ICS FRM 2.15

Issue 04 Rev. 2
1 of 4
Part One

Name of Organization: ......................................................................................................................

Address: ......................................................................................................................

(See Note 1) ......................................................................................................................

......................................................................................................................

Telephone: ................................... Facsimile: ......................................

NPWP No.: ......................................................................................................................

I on behalf of the organization detailed above hereby apply for certification and declare that we agree to
comply with SUCOFINDO INTERNATIONAL CERTIFICATION SERVICE (SUCOFINDO ICS) Terms and
Conditions Governing System Certification and that the information given in this application and the attached
questionnaire (see Note 2.) is correct.

............................................ ........................................... ............................................ .............................

(Signature) (Name) (Position) (Date)

I nominate the following person as our Authorized Representative (see Note 3):

Authorized Representative: ......................................................................................................................

Position: ......................................................................................................................

Postal Address: ......................................................................................................................

......................................................................................................................

......................................................................................................................

Telephone: ...................................... Facsimile: ......................................

............................................ ............................................ ............................................ .............................

(Signature) (Name) (Position) (Date)

I. ............................................................................................, hereby accept nomination as my

organization’s authorized representative for SUCOFINDO ICS Certification. I declare that I will observe the
Terms and Conditions Governing System Certification and authorize you, on certification of the organization,
to enter my name in the Directory of Certified Organizations.

............................................................................... ..........................................
(Signature) (Date)

SUCOFINDO ICS FRM 2.15

Issue 04 Rev. 2
2 of 4
Part Two

Please indicate to which standard certification is being sought

(e.g. ISO 9001, ISO 14001, HACCP, etc)

Please detail the scope of certification being sought and exclusion requirement (for ISO 9001:2000 only].

(e.g. Manufacturing of textile toys; fabricated metals; room air conditioner; life insurance; cargo handling)

Notes

Note 1 If the scope of your application covers more than one location, please enter details on page
four (4) of this application. Photo copies of page 4 can be made and attached to the
application form if required.

Note 2 In additional to this application can you please complete the applicable section of
SUCOFINDO ICS System Certification Questionnaire and attach it to this application.

Note 3 The authorized representative is the person nominated by an organization to represent it in all
matters affecting the organization’s certification by SUCOFINDO ICS.

The person must formally accept the nomination as authorized representative as this is a
requirement of SUCOFINDO ICS’s requirements.

It may be of advantage to have the position of “authorized representative” held by the person
in the organization fulfilling the role of “management representative”, as defined in
ISO 9001/ISO 9002 Clause 4.1.2.3. and ISO 14001 Clause 4.4.1

Please forward this application form to :

SUCOFINDO INTERNATIONAL CERTIFICATION SERVICES
Graha Sucofindo 10th Floor
Jl. Raya Pasar Minggu Kav.34
Jakarta Selatan 12780 - Indonesia.
Phone. + 62-21-7983666 Ext.1021 or 1040
Fax. + 62-21-7987015

SUCOFINDO ICS FRM 2.15

Issue 04 Rev. 2
3 of 4
Additional Locations

Name of Location: ......................................................................................................................

Address: ......................................................................................................................

......................................................................................................................

......................................................................................................................

Telephone: ...................................... Facsimile: ......................................

Local contact: ......................................................................................................................

Name of Location: ......................................................................................................................

Address: ......................................................................................................................

......................................................................................................................

......................................................................................................................

Telephone: ...................................... Facsimile: ......................................

Local contact: ......................................................................................................................

Name of Location: ......................................................................................................................

Address: ......................................................................................................................

......................................................................................................................

......................................................................................................................

Telephone: ...................................... Facsimile: ......................................

Local contact: ......................................................................................................................

Name of Location: ......................................................................................................................

Address: ......................................................................................................................

......................................................................................................................

......................................................................................................................

Telephone: ...................................... Facsimile: ......................................

Local contact: ......................................................................................................................

SUCOFINDO ICS FRM 2.15

Issue 04 Rev. 2
4 of 4