Topco Supplier Intake Form

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Supplier Name

Supplier Location Information

Name of Location Requesting Approval

Type of facility requesting approval

Are the products manufactured at this facility consumable?

YesNo

Manufacturing ID Number and/or USDA Establishment Number (if regulatory plant id number is available)

Is this facility registered with the U.S. FDA?

YesNo

If no, please provide details

Bioterrorism Registration Number

Address of Location Requesting Approval

Street Address

Apt/Suite Number

City

State

Postal/Zip Code

Country

Does this facility manufacture, process, pack, or hold Food or food contact products?

YesNoFood contact materials include, but are not limited to: paper plates, foam plates, paper cups, plastic cups, foam cups, plastic cutlery, plastic food storage bags, plastic food storage containers, plastic food wrap, aluminum foil, cookware, bakeware, utensils, flatware, plastic clamshells, paper food wrap, cooking appliances, china, plastic bottles, foil and paper food bags, measuring cups, etc.

Facility Audit Information

What is your current GFSI Audit Score?

What is your current GFSI Audit Rating ?

[ **** ][ *** ][ ** ][ * ]

What is your current GFSI Audit Status?

CertifiedNon Certified

When does your current GFSI Audit expire?

Did you receive any Critical or Major Non-Conformance in your current audit?

YesNo

What was your GFSI Audit Scores for the last 3 years?

Audit Score Year 1

Audit Score Year 2

Audit Score Year 3

What was your GFSI Audit Status for the last 3 years?

What was your GFSI Audit Grade for the last 3 years?

REQUIRED: Upload most recent GFSI certificate (missing required documentation will result in automatic rejection)

REQUIRED: Upload most recent GFSI audit and corrective actions (missing required documentation will result in automatic rejection)

Is this facility inspected by a Third Party or certified under a GFSI scheme?

YesNo; Third Party Inspections or certification under a GFSI scheme is required for Topco suppliers. Social Compliance Audits and Social Responsibility Audits do not meet the Topco GMP Audit requirements, but GMP Audits are a requirement for Topco such as GRMA 455 Based Audits. Please reach out to your primary Topco contact before completing the remainder of this questionnaire.

REQUIRED: Upload most recent Third Party Inspection Report and corrective actions or most recent GFSI certificate, audit and corrective actions.

REQUIRED: Upload a copy of the company organizational chart showing QA/QC/Sanitation and Regulatory

REQUIRED: Upload a copy of the Production Floor Plan

REQUIRED: Upload FSMA food safety plan or HACCP Plan

REQUIRED: Upload HACCP process flow chart

Has this facility had a classified recall within the last 5 years?

YesNo

Provide specifics of classified recall(s)

REQUIRED: Upload the Corrective Action to the Recall

All suppliers must report any recall, potential recall, potential hazard or consumer safety situation(s) in accordance with regulation to the appropriate Government, including Federal, State and Local Regulatory Agencies.

I acknowledge this reporting responsibility and have the ability to comply, as applicable.

In the last 5 years, has this facility received a FDA 483 notice and/or received an FDA warning letter?

YesNo

Describe issues and corrective actions

REQUIRED: Upload a document describing this facility's Good Manufacturing Practices (GMPs)

FSVP Compliance

Are products under consideration by Topco that are packed in the facility covered under FSVP(full or modified requirements)?

YesNo

State the reasoning why these products are not covered under FSVP (full or modified requirements)

Such as but not limited to Covered under Juice HACCP, Covered under Seafood HACCP, Domestic, Exempt, further process, USDA Regulated.

	Yes	No
Are you familiar with or have working knowledge of FDA Foreign Supplier Verification Program(FSVP)? Click HERE for more information.
Are you already shipping products from this facility into the US to another customer?
Has this facility received any US Import Alerts in the past 5 years?

How many import alerts related to your products have been issued in the past 5 years?

Describe the nature of each import alert

Describe the learnings from each import alert

Describe how each import alert was closed out

Who will be the FSVP importer?

Your CompanyOther EntityTopco(Do not select this option unless you have received approval from your Topco Sourcing/Category counterpart)Please utilize the hyperlink for definition of facilities and importers.

FSVP Contact Information

Company name of US entity that will bear regulatory responsibility under FSVP regulations

Address of US entity that will bear regulatory responsibility under FSVP regulations

Contact Name of US entity that will bear regulatory responsibility under FSVP regulations

Contact phone number of us entity that will bear regulatory responsibility under FSVP Regulations

Please provide numbers only.

Contact Email of US entity that will bear regulatory responsibility under FSVP regulations

DUNS # of US entity that will bear regulatory responsibility under FSVP regulations

Name the Topco Contact who granted approval for Topco to be named FSVP importer

* If you have not received Topco approval to proceed with Topco as FSVP importer do not complete this questionnaire. Please contact your Topco Sourcing/Category counterpart for approval before proceeding.

Is this facility compliant with any of the following FSMA rules (check all that apply)

Preventive Controls for Human FoodPreventive Controls for AnimalsProduce SafetyNo

Enter date by which facility will be compliant with this rule

	499 or less	500 or more
What is the total number of full time employees for your business entity including all affiliates and subsidiaries?

Supplier Expectations

Supplier Quality and Safety Expectations Guide

Topco Quality Assurance has developed a Supplier Quality and Safety Expectations Guide. Click here to review the guide and acknowledge receipt by checking the box below.

Acknowledgement

I acknowledge the receipt of the Topco Supplier Product Quality and Safety Expectations Guide. I have reviewed and understand the contents of the guide in its entirety and have conveyed the details to all necessary parties within my organization.

Primary QA Contact Information

QA Contact First Name

QA Contact Last Name

QA Contact Title

QA Contact Phone Number

QA Contact Cell Phone Number

QA Contact Email

Secondary QA Contact Information

Contact First Name

Contact Last Name

Contact Title

Contact Phone Number

Contact Cell Phone Number

Contact Email

Regulatory Contact Information

Labeling Contact First Name

Labeling Contact Last Name

Labeling Contact Title

Labeling Contact Phone Number

Labeling Contact Email

Contact Information for Person Completing Questionnaire

First Name

Last Name

Title

Phone Number

Email Address

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Contact Information

	[ AA+]	[ A+ ]	[ AA ]	[ A ]	[ AA- ]	[ A- ]	[ B and Lower ]
Audit Grade Year 1
Audit Grade Year 2
Audit Grade Year 3

Dairy/Milk Products	Eggs	Fish	Peanuts	Sesame
Shellfish	Soy	Tree Nuts	Wheat	None