LAMPIRAN 2
KEMENTERIAN KESIHATAN MALAYSIA
MINISTRY OF HEALTH
BORANG PERMOHONAN SIJIL KESIHATAN BERDASARKAN KEPADA
PRODUK MAKANAN DAN BAHAN BERSENTUHAN MAKANAN /
APPLICATION FORM FOR HEALTH CERTIFICATE BASED ON FOOD
PRODUCTS AND FOOD CONTACT MATERIALS
Jenis Sijil Kesihatan/Type of Health certificate (Sila tanda (√) / Please tick (√)):
Makanan Am
Daging Yang Diproses Haba
Udang Beku Yang Telah Dimasak
Air Minuman Berbungkus
Air Mineral Semulajadi
Minyak Makan Kelapa Sawit dan Minyak Isirung Sawit
* Ikan dan Hasilan Ikan
Ikan dan Hasilan Ikan ke Negara China
* Sarang Burung Walit ke Negara China
Bahan Bersentuhan Makanan
* Health Certificate for Export of Aquatic Animals and Their Products
Intended for Retail Use/Food Service to Canada
Tujuan Permohonan (Reason for Application): Eksport (Export) Pameran (Exhibition) Bukan komersil (Non-commercial)
* Sila rujuk kepada SOP yang berkaitan sebelum membuat permohonan (Kindly refer to the
related SOP before submitting your application)
BKKM/HC/F/01
A. Maklumat Pemohon/Particulars of Applicant
1.1 Nama Pemohon (Name of Applicant)
1.2 No.Kad Pengenalan/ Passport (NRIC/Passport Number)
1.3 Nama dan Alamat Syarikat (Name and Address of Company)
1.4 No. Tel (Tel. No.) 1.5 No. Faks (Fax No.)
1.6 No. H/P (H/P No.) 1.7 Alamat E-mail (E-mail address):
1.8 Alamat surat menyurat jika berlainan dengan 1.3 (Correspondence Address (if different from 1.3))
1.9 No. Pendaftaran Premis dengan KKM (Registration number of food premises with Ministry of
Health) (Sila lampirkan sesalinan sijil atau slip perakuan/Please attach a copy of the certificate or confirmation
slip)
1.10 No. Pendaftaran Syarikat (Company Registration Number (ROC) (Sila lampirkan sesalinan
sijil/Please attach copy of the certificate)
1.11 Nombor pendaftaran dengan negara pengimport atau permit import (Registration number with
importing country or import permit number)
1.12 Nama dan alamat pengeksport /konsainor (Name and address of exporter/consignor)
1.13 Nama dan alamat pengimport /konsaini (Name and address of importer/consignee)
1.14 Nama dan alamat premis pemprosesan (Name and address of processing establishment)
1.15 Nama dan alamat Pembungkus (Name and address of Packer)
1.16 Tempat Pensampelan (Sampling Point)
BAGI PERMOHONAN SIJIL KESIHATAN AIR MINUMAN BERBUNGKUS DAN AIR MINERAL
1.17 Jenis botol (Type of bottled water)
1.18 No. Kelompok (Batch No) 1.19 Tarikh luput (Expiry date)
BAGI PERMOHONAN SIJIL KESIHATAN DAGING DIPROSES HABA
1.19 No. Pengenalan (Lak) (Identification No.)
B. Maklumat Pengangkutan / Particulars of Transport
1.17 Tarikh Pelepasan (Date of Departure) : 1.18 Pelabuhan Pelepasan (Port of Shipment)):
1.19 Destinasi (Destination):
1.20 Cara Pengangkutan (Means of Transport): Kapal (Vessel) Kapal terbang (Flight) Trak/Lori (Truck/Lorry) Lain-lain (Others) sila nyatakan (please specify)…………………..
1.21 Nama Kapal (Name of Vessel) 1.22 Nombor Penerbangan/Plet Trak
(Flight/Plate Truck Number)
1.23 Nombor Konsainan (Consignment No.) 1.24 Nombor Kod & Siri (Code and Serial No.)
C. Maklumat Konsaimen/ Description of Consignment Sila isi ruangan yang berkenaan dan gunakan helaian yang berlainan jika diperlukan (Please fill in related space and use separate sheet if required)
1.25
Bil
(No)
1.26 Nama
Produk
(Name of
Product)
*1.27
Nama
Biasa
(Common
Name)
1.28
Cop
dagang/
(Trademark)
^1.29
Spesis
(Species)
^1.30 Jenis
pemprosesan
(Process
ing type)
^1.31 Mod pemprose
san (Procesin
g Mode)
*1.32 Jenis
penyakit yang
berkaitan (Type of
related disease)
^1.33 Jenis Produk – akuakultur atau liar (Type of Product –
aquaculture or wild catch)
!^1.34 Negara asal (Country of
origin)/ # Sumber
Bahan Mentah
(Source of Raw
Material)
1.35 Kuantiti
(Quantity)/ Saiz (Size)
1.36 Berat (Net
weight) (kg/
tonnes)
^1.37 Tarikh
pemprosesan
(Productio
n date) 1.33a Nama & Tempat Ladang
Akuakultur
(Name
And Area Of
Aquacultured
Product)
1.33b Kawasan Tangkapan (Catch
Area)
* Bagi permohonan Health Certificate for Export of Aquatic Animals and Their Products Intended for Retail Use/Food Service to Canada (For the application of Health Certificate for Export of Aquatic Animals and Their Products Intended for Retail Use/Food Service to Canada) ! Bagi permohonan Sijil Kesihatan Daging yang Diproses Haba (For the application of Health Certificate for Heat Processed Meat) ^ Bagi permohonan Sijil Kesihatan Bagi Ikan dan Hasilan Ikan ke China dan Health Certificate for Export of Aquatic Animals and Their Products Intended for Retail Use/Food Service to Canada (For the application of Health Certificate for Fish and Fishery Product to China dan Health Certificate for Export of Aquatic Animals and Their Products Intended for Retail Use/Food Service to Canada) # Bagi permohonan Sijil Kesihatan Sarang Burung Walit ke China (For application of Health Certificate for Edible Bird Nest to China)
Saya / I, …....................................................., (Nama Pemohon) (Name of Applicant)
dengan ini mengaku bahawa ke semua maklumat yang diberikan di atas adalah benar.
hereby, declare that all the above information is true.
Tarikh / Date : …................................ Cop syarikat / Company stamp
….......................................................
Tandatangan pemohon/ Signature of applicant
E. STATUS PERMOHONAN/STATUS OF APPLICATION
No. rujukan / Reference. No.: Tarikh terima / Date of receipt:
Status permohonan/ Status of Application:
i. Terima / Accept ii. Tolak / Reject
Disemak oleh/ Checked by Disahkan oleh/ Verified by
Nama/Name :...................................... Nama/Name:..........................................
Tarikh/Date :...................................... Tarikh/Date: ..........................................
D. Perakuan Pemohon/ Declaration of Applicant
LAMPIRAN 3
KEMENTERIAN KESIHATAN MALAYSIA
SENARAI SEMAK PERMOHONAN SIJIL KESIHATAN BERDASARKAN PRODUK MAKANAN DAN BAHAN BERSENTUHAN MAKANAN
APPLICATION FORM FOR HEALTH CERTIFICATE BASED ON FOOD PRODUCTS AND FOOD CONTACT MATERIALS
Bil Perkara Ada ( √ ) / Tiada ( X )
Catatan
1. Borang PKKM/HC/F/01;
2. Salinan Pendaftaran Perniagaan Syarikat;
3. Salinan Sijil Pendaftaran Premis dari KKM, atau slip pendaftaran Fosim Domestik
4. Sebarang dokumen yang membuktikan syarikat beroperasi dengan sah di premis pemohon dari agensi kerajaan yang berkaitan seperti lesen kilang atau lesen perniagaan;
5. Salinan lesen eksport agensi;
6. Salinan penyertaan pameran anjuran badan kerajaan (jika berkaitan);
7. Label produk (jika berkaitan);
8. Salinan Sijil Kelulusan punca air dari KKM (jika berkaitan)
9. Senarai keperluan negara pengimport
10. Salinan Sijil HACCP dari KKM (jika ada )
11. Lain-lain dokumen (jika berkenaan, nyatakan)
Status: Lengkap Tidak Lengkap
Catatan: ...................................................................................................................................
Disediakan oleh:
Nama:..........................................................................................................................
Jawatan:........................................................ Tarikh:.......................................
PKKM/HC/CL-01
