Change Request and Notification Form Change Request and Notification Form This form is to be used by the Certification Bodies to request date changes for their sites or to notify us of suspensions and withdrawals. All requests must come from a certification body. The reason for change box must be detailed to allow for a decision on any date change requests. You will receive a response back in the form of an e-mail announcing the decision for all date change requests. ALL PARTS OF THE FORM ARE REQUIRED TO BE FILLED IN. Certification Body Contact*Please enter your first and last name. First Last Contact Email*Please enter your email address. Date of Request* Date Format: MM slash DD slash YYYY Certification Body Name*(Select Your Certification Body)AIBI Certification ServicesASI Food SafetyAsureQuality LimitedAUS-QUAL Pty LtdbQb Cert LLCBSI Group ANZ Pty LtdBureau de Normalisation du QuebecBureau Veritas Certification NACICS Americas Inc.dicentra Global CertificationsDNV GLDQS Inc.EAGLE Food Registrations, Inc.EurofinsFIRDI (Food Industry Research and Development Institute)FoodChain ID CertificationFSNS Certification and Audit LLCGlobal Standards CertificationIntertek Testing Services NA, Inc.Lloyd's RegisterMérieux NutriSciences CertificationNSF Certification, LLCOCETIFPerry Johnson Registrars Food Safety, IncPwC CertificationSafe Food CertificationsSAI GlobalSCS Global ServicesSGS Systems & Services Certification Pty LtdTSL Certification Services International LTD.TUV NORD CERT GMBHTUV SUD America Inc.UL Registrar, LLCValidusWQS LLCFacility Name*Please enter this site's Facility Name as shown in ReposiTrakRequest Number*Please enter this site's last known FINISHED request number as shown in ReposiTrak.Site Location State*Please enter this site's state if located within the United States of America(Select the Facility State)Not ApplicableAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingSite Location StateHIDDENSite Location Country*Please enter the country this site is locatedFacility ID*Please enter this site's Facility ID as shown in ReposiTrakOriginal Certification Expiration Date* Date Format: MM slash DD slash YYYY Current Recertification Audit Date* Date Format: MM slash DD slash YYYY Requested Change Date* Date Format: MM slash DD slash YYYY Requested Change*(Select Your Change Request)Audit Window Change - PermanentAudit Window Change - TemporaryAudit Window Change - Temporary (Coronavirus)Audit Window Change - Temporary (Natural or Manmade Disaster)Certificate Expiration Date ChangeCertificate Status Change - SuspensionCertificate Status Change - WithdrawalSurveillance Audit ChangeExtension of time between remote and on-site activityOtherCertificate ID*2020 Audit Request Number*Reason for Change*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.