SUPPLIER APPROVAL FORM - Lange Fresh Sales

How To Complete The Packet: To continue as an approved Lange Fresh Sales, Inc. supplier, please follow the instructions below and provide all required documentation.

Complete and return all items to foodsafety@langefreshsales.com
Electronic copies in PDF form at www.lange-companies.com

REQUIRED DOCUMENTATION:

1. SUPPLIER PROFILE

2. SUPPLIER WARRANTY AND INDEMNIFICATION AGREEMENT

3. BE/GMO AFFIDAVIT

4. FSVP (FOREIGN SUPPLIER VERIFICATION PROGRAM)

5. FOOD SAFETY CHECKLIST

6. PROOF OF RECALL INSURANCE

7. CERTIFICATE OF INSURANCE

a. General Liability

b. List the certificate holder as “Lange Companies, Inc. and its subsidiaries”

8. W-9 FORM

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Please enter all that apply:

PACA License No.

Bluebook I.D.

MC#

COMPANY TYPE: Please check the appropriate box that describes your business: *

Products Supplied *

Contact for Purchasing | Sales

Purchasing Contact *

Title *

Phone *

Email *

Contact for Food Safety | Recall

Food Safety Contact *

Title *

Phone *

Email *

24 hour Emergency Contact Name *

Phone *

Email *

Bio-Engineered/Genetically Modified Organism (GMO) Affidavit

Company Name *

Address *

City *

State *

Zip Code *

As a supplier of Lange Fresh Sales, Inc., we hereby attest that: *

all product(s) we supply are not Bio-Engineered and/or do not contain GMOs (Genetically Modified Organisms) nor has it been produced using genetically engineered organisms.

some or all product(s) we supply are Bio-engineered and/or contain GMOs (Genetically Modified Organisms) and/or has been produced using genetically engineered organisms.

If GMO's, ARE present, please indicate the commodities below, by ITEM, BRAND, PACKAGING TYPE:

If, for any reason, there are any modifications in the product list, you are responsible for notifying us immediately.

Company Name *

Title *

Signature *

clear

Date * +

FSVP (FOREIGN SUPPLIER VERIFICATION PROGRAM)

Effective May 30, 2017 FDA has confirmed recognition of the DUNS number, assigned and managed by D&B, as an acceptable Unique Facility Identifier (UFI) for the purpose of compliance with the FSVP (Foreign Supplier Verification Program) regulation. In light of the new rule, Lange Fresh Sales, Inc. requires written assurance from its suppliers that under NO circumstances will the DUNS number of Lange Fresh Sales, Inc. or its subsidiaries be listed as the UFI for any imported products, nor will Lange Fresh Sales, Inc. be listed as the “owner” or “consignee” for any shipment.

Please check both boxes below to indicate your acceptance: *

Under NO circumstances will the DUNS number of Lange Fresh Sales, Inc. or its subsidiaries be listed as the UFI for any imported products.

Under NO circumstances will Lange Fresh Sales, Inc. or its subsidiaries be listed as the “owner” or “consignee” for any shipment.

Company Name *

Title *

Full Name *

Signature *

clear

Date * +

Food Safety Checklist

All food safety audits must be an approved GFSI scheme (i.e., PrimusGFS, GLOBALG.A.P., SQF, CANADAG.A.P.) The Global Food Safety Initiative is an industry-driven global collaboration to advance food safety.

Please check all that apply and send attachments to: foodsafety@langefreshsales.com

Current food safety 3rd Party Audits for all:

Ranch, Harvest Crew, Packinghouse/Cooler

Final Audit Report,

Corrective Action Report (CAR)

Certificate

Organic Certificates, if applicable:

Growing operations

Packinghouse/Cooler

If supplying imported product:

Social Compliance Audits