FOOD CONTROL SECTION

GROUP ENVIRONMENT, HEALTH & SAFETY DEPARTMENT

APPLICATION TO DESTROY FOODSTUFF

FCS FORM NO.: 4 REFERENCE NO.: __________________

COMPANY NAME CONTACT PERSON:

P.O. BOX NUMBER: TELEPHONE NUMBER FAX NUMBER

DETAILS OF FOODSTUFF FOR DESTRUCTION

NO. DESCRIPTION BRAND QUANTITY QUALITY TOTAL INVOICE

NAME WEIGHT NUMBER
1
2
3
4
5
6
7
REASON FOR DESTRUCTION:

DESTRUCTION CERTIFICATE REQUIRED NOT REQUIRED

SIGNATURE OF COMPANY’S REPRESENTATIVE / STAMP:

FOR GROUP ENVIRONMENT, HEALTH & SAFETY USE ONLY

(DESTRUCTION DETAILS)
DESTRUCTION APPOINTMENT:

TIME: ________________________________ LOCATION: _____________________________

DESTRUCTION FEE: RECEIPT NUMBER DATE

DESTRUCTION OF GOODS WAS CARRIED OUT UNDER EHS-FZ DEPT. SUPERVISION:

NAME: ____________________________ SIGNATURE: ________________________ DATE: ___________

CUSTOMS REPRESENTATIVE:

NAME: ___________________________ SIGNATURE: ________________________ DATE: ___________

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PORTS, CUSTOMS AND FREE ZONE CORPORATION

P.O.Box 17000, Dubai, United Arab Emirates
Tel.:971-4-8815000, Fax : 971-4-8817023