Application to Amend Conditions of Approval As a Food Auditor

Application form / Food Act 2006

Application to amend conditions of approval

1. Applicant Details

Title / Mr Ms Mrs Miss Dr / Surname
Given names (do not abbreviate) / Preferred name
Residential address
Postal address / as above, or other:
Telephone / Mobile

2. Employment/business details

Business/trading name / ABN
Company name / ACN
Street address
Postal address / as above, or other:
Telephone / Mobile
Contact email
Note: Contact details provided for the applicant in this section will be recorded on the register of approved auditors.
Where would you like correspondence sent? Residential Business

3. Amendment to scope

I apply for amendment of the conditions of my approval as an auditor under the Food Act 2006 to include the following scope/s:
Cook chill processes / Heat treatment processes
Successful completion of the relevant competency unit/s specified belowismandatory for approval to conduct audits under the Food Act 2006 for the requested scope/s.
Evidence of successful completion of the required qualifications are attached:
Cook chill processes / FDFAU4006A (or FDFFSCC4A) Audit a cook chill process / Yes No
Heat treatment processes / FDFAU4007B (or FDFFSHT4A)Audit a heat treatment process / Yes No

4. Disclosure-attach any relevant documentation

Have you:
been convicted of an indictable offence (drink driving and minor traffic offences are not indictable)? / Yes No
been convicted of an offence against the Food Act 2006, Food Regulation 2006 or a repealed provision or a corresponding law? / Yes No
held or applied for an approval or a licence under the Food Act 2006 or a repealed provision or a corresponding law that was refused, suspended, cancelled or any other action imposed upon it? / Yes No
been convicted of an offence relating to a food business and/or auditing activity against the:
(i)Work Health and Safety Act 2011;
(ii)Another law applying or that applied in the State, Commonwealth, another state or a foreign country;
(iii)A repealed provision or a corresponding law? / Yes No
been subjected to disciplinary action relating to an auditing activity under the Queensland Building and Construction Commission Act 1991, the Domestic Buildings Contract Act 2000, the Queensland Civil and Administrative Tribunal Act 2009 or a repealed provision or a corresponding law? / Yes No
been subject to, or are the subject of, disciplinary action in any State, Territory or New Zealand relating to a food business or auditing activity (including preliminary investigations or action that might lead to disciplinary proceedings)? / Yes No
ever been prohibited from performing auditing activities in any State, Territory or New Zealand and are not subject to any special conditions in carrying on auditing activities, as a result of criminal, civil or disciplinary proceedings in any State, Territory or New Zealand? / Yes No
Do you have any direct or indirect financial interest or other interest in a food business that could conflict with the proper performance of your functions as an auditor?
If yes, please provide details of this interest in the form of an attachment. / Yes No
*If any questions are answered ‘YES’, please attach documentation that provides details of the offence, the nature of the offence and the circumstances of its commission. Applicants are advised that the Department of Health may, in certain circumstances, provide the information contained in this application to relevant external agencies.

5. Declaration

I apply to the chief executive to amend the conditions of my approval as an auditor under the Food Act 2006 and enclose the prescribed fee identified at section 8 and all required supporting documentation. / Yes No
I declare that the information stated in this application form to the best of my knowledge is true, correct and complete. / Yes No
I declare that I have read, understood and agree to comply with the Code of Conduct for approved auditors, Food Act 2006. / Yes No
I consent to a criminal history check being conducted through the Queensland Police Service in deciding if I am a suitable person to be an approved auditor. / Yes No
I declare that I have an adequate level of professional indemnity insurance. / Yes No
I consent to the making of enquiries of, and the exchange of information with the authorities of any State, Territory or Commonwealth regarding my activities as an auditor and any matters relevant to this application. / Yes No
I understand that Queensland Health may conduct check audits of accredited food safety programs I have audited. I understand that the check audits may include an assessment of the accuracy of the audit report. / Yes No
I understand that my details including name, relevant contact details and conditions of approval will be published on the Department of Health register of approved auditors, which is publicly available. / Yes No
Signature / Date
Privacy Statement: The Department of Health provides this form under the Food Act 2006 so that you may apply to the chief executive for amendment of conditions of approval as an auditor. The information and documents collected for the purpose of this application may be accessible by appropriately authorised officers of the department or its agents. The department will not disclose your personal information or supporting documents to third parties without your consent unless required or authorised by law.
The Information Privacy Act 2009 sets out the rules for the collection and handling of personal information by the Department of Health. For information about how the Department of Health protects your personal information, or to learn about your right to access your own personal information, please see our website at
7. Payment of fee
tick1 box only
Cheque or Money Order enclosed (payable to Queensland Health)

Payment by Credit Card (section 5)

Note: This is a GST free item. Department of Health ABN 66 329 169 412

The application fee is non-refundable.

8. Credit card payments

This page should only be completed if payment is being made by MasterCard or Visa
American Express is NOT available
Name of applicant
Prescribed fee: / $ / Please tick / MasterCard / Visa
Card No.
Expiry date:
Name on card (please print)
Signature of cardholder

Return the completed application to:Food Safety Standards and Regulation

Health Protection Branch

PO Box 2368

FORTITUDE VALLEY BC QLD 4006

or

Further information

Further information is available via the Queensland Health website
Enquiries can be directed to Food Safety Standards and Regulation by phone (07) 3328 9310 or email .

Food 03.1/September 2015: Application form – Amend approval / - 1 -