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U.S. Department of Health and Human Services

Food

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TPC APPLICATION FORM

<< Back to Index of Memoranda of Information (M-I) Main page

Third Party Certifier (TPC) Application for the NCIMS Voluntary
International Certification Program (ICP)
A. TPC Name:
TPC Address:
B. TPC Most Responsible Individual: (Owner or Corporate Officer)
Title:
Mailing Address:
City:
State/Country:
Zip/Country Code:
Telephone Number(s):
Fax Number:
Email Address:
C. Authorized Representative (Foreign Applicants):
Title:
Mailing Address:
City:
State/Country:
Zip:
Telephone Number(s):
Fax Number:
Email Address:
D. Contact Person: (The contact person shall be the person to whom questions about the content of the application may be addressed and the person to whom a letter of determination and general correspondence will be directed.)

Title:

Mailing Address:
City:
State/Country:
Zip:
Telephone Number(s):
Fax Number:
Email Address:
E. Brief Description of the TPC: (Type of organization, size of organization (number of employees); number of years in operation both domestic and foreign; nature, examples and location of Grade “A” and non-Grade “A” dairy work (e.g. Regulatory, Rating, Laboratory, name and location of reviewed facility etc.); and information regarding ownership, operation, and control of organization sufficient to assess its degree of independence from manufacturers, producers, and distributors.)






















 
F. Types of Dairy Facilities the TPC Proposes to Regulate and Rate/List: (Dairy Farms, Bulk Milk Hauler/Samplers, Milk Tank Trucks, Industry and/or Dairy Plant Samplers, Transfer Stations, Receiving Stations, Milk Plants, Analysis of Raw Milk Samples, Analysis of Pasteurized Milk Product Samples, Analysis of Single-Service Containers and Closures, Laboratory Certification(s), etc.)











G. Names and Functions of TPC Designated Personnel: (Administrative Personnel; Regulatory Inspectors (dairy farm, milk tank truck, bulk milk hauler/samplers, milk plants, etc.); proposed Sampling Surveillance Officers (SSOs); proposed Milk Sanitation Rating Officers (SROs) (dairy farms, receiving stations, transfer stations, milk plants or a combination of any of the above, and/or the HACCP Auditing/Listing of transfer stations, receiving stations, and/or milk plants, and/or the Aseptic or Retort Listing of milk plants; proposed Grade “A” Milk Laboratory(ies); and/or proposed Grade “A” Milk Laboratory Evaluation Officers (LEOs). For SSOs, SROs and/or LEOs that are not currently FDA certified, what are your plans for these individuals to become FDA certified?)






















 
H. List any National, State, Local, or other Accreditations or Previous FDA Certifications obtained by the TPC or Designated Personnel (include Accreditation/Certification titles, certificates and dates):












List any Applicable Grade “A” Milk Safety Program Training Received, e.g,. FDA sponsored Grade “A” Milk Safety Training Courses (include training course titles, certificates and dates):









 
I. Prevention of Conflicts of Interest:
The applicant shall submit a copy of the written policies and procedures they have established to ensure that the firm seeking to participate in the ICP and their employees (including contract employees) are free from conflicts of interest. The ICPC will assess these written policies and procedures to ensure that the concerns relating to potential conflicts of interest are addressed. Successful applicants must sign a certification provided by the ICPC regarding prevention of conflicts of interest.
J. Indemnification:
The applicant hereby agrees to indemnify and hold harmless all members of the National Conference on Interstate Milk Shipments (NCIMS), including but not limited to, all members of the NCIMS International Certification Program Committee, all federal regulatory agencies including the U.S. Food and Drug Administration, all State Regulatory Agencies, all trade associations including the International Dairy Foods Association and the National Milk Producers Federation, and all private entities including companies and consultants, and their respective members, agents, officers, directors and employees, against any and all losses, liabilities, costs, actions, claims and other obligations and proceedings, including any reasonable attorney’s fees incurred in connection with, or which may arise or result in any way from the operation of the NCIMS Voluntary International Certification Program.
K. Personnel Qualifications:
The ICPC will consider several factors with respect to personnel qualifications including: NCIMS milk program related experience, previous milk program related training, program related certifications, i.e., Rating Officer, Sampling Surveillance Officer, Laboratory Evaluation Officer, etc., technical knowledge (of milk plant and dairy farm operations), training and the preparedness of the TPC’s employees to conduct the routine regulatory functions of the program within the guidelines of the program. The following factors shall be documented and attached to this application:
  1. Written instructions for the duties and responsibilities of designated personnel; and
  2. Written personnel qualification standards you have established to ensure that designated personnel are qualified, knowledgeable and properly trained.
Documentation (e.g., resumes or CVs) to establish that designated personnel meet the established qualification standards. This includes documentation of education, training, skills, knowledge, abilities and experience, including specialized education and experience needed for the review.






L. Affirmations:
By signature below the Most Responsible Individual at the TPC affirms that, if chosen to participate in the ICP, the TPC will:
  1. Accurately report inspectional findings and, if applicable, laboratory results and Rating determinations;
  2. Limit the work of personnel to that for which they are competent and have the capacity and are available to perform the assigned function;
  3. Treat information received, records, reports, and recommendations as proprietary information;
  4. Promptly respond and resolve complaints regarding its activities;
  5. Protect against a conflict of interest by any officer or employee of the firm; and
  6. Comply with the ICP Code of Ethics
Name: ____________________________
Title: ______________________________
M. Training Requirement:
By signature below the Most Responsible Individual at the TPC certifies that if chosen to participate in the ICP, designated employees of the TPC will attend FDA training in accordance with NCIMS requirements.
Name: ____________________________
Title: ______________________________
N. Additional Required Documents: TPC Applicant should attach the following documents to the completed application:
  1. The TPC Applicant's written Conflict of Interest Policies and Procedures (Section I); and
  2. Personnel Qualification Documentation (Section K);
We hereby agree to and submit this application knowingly and voluntarily. With this completed application, we request consideration for participation in the NCIMS Voluntary International Certification Program.
TPC Most Responsible Individual: __________________________
Title: ________________________________________________
Date: ________________________________________________