Chemical Evaluation Form

GENERAL INFORMATION

Supplier Name:

Product/Service:

NTN Number

Address

Street #

City

State

Zip Code

Country

Phone/Mobile

Fax

Contact Person

Designation

Contact

FACILITY PROFILE

Year Established

Major Customers

Please Provide ISO 9001 Document

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Please Provide ISO14001-2015 Documents.

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Please Provide OEKOTEX Documents.

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Please Provide OCS/GOTS Documents.

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Please Provide ZDHC Documents.

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Please Provide GreenScreen Documents.

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Please Provide Related Documents.

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General Evaluation Parameters

- Are you a self manufacturer or Importing Chemicals and distributing to Customer?

Manufacturer

Distributor

- Do You Have an Organization chart with responsibilities assigned? (please attach Technical Person Contact and detail)

Yes

- Do you have a system to train your new and existing staff? (If yes Please Share Details)

Yes

- Will You provide MSDS (Material Safety Data Sheets) with all your chemicals? (All 16 Sections or Certified)

Yes

- Will You provide TDS (Technical Data Sheets) with all your chemicals? (Batch Number must be mentioned)

Yes

- Do you do internal Inspection of the Process and do you maintain its record?

Yes

- Will you provide the Chemical Test reports at the time of delivery? (providing Expiry Date) Mandatory

Yes

Does Original Pasted Labels from Manufacturer will be pasted on the Product Packages along with Hazardous Symbols for these Chemicals? (Labelling as per GHS Standard and Expiry Date/Lot Number merntioned in it.)

Yes

- Do You Perform Inspection & Testing at

A- Incoming Stage

B- In Process Stage

C- Final Stage

- Do you have Customer Complaint System and Its Log Available?

Yes

- Is there any system implemented to control harmful and banned substances?

Yes

Please confirm Details you will provide on the Labels of the Container

A. Manufacturer Name

Yes

B. Product Identifier

Yes

C. Hazard Pictogram

Yes

D. Signal Word

Yes

E. Precationary Statement

Yes

F. Hazrad Statements, if any

Yes

G. Batch Number

Yes

H. Manufacturing Date

Yes

I. Expiry Date

Yes

j. Weights

Yes

If you are registered in ZDHC following applicable testing is required by 17025 Accredited laboratory

1. Azo/Arylamine

Yes

2. APEO

Yes

3. Formaldehyde

Yes

4. Phenols

Yes

5. Heavy Metals

Yes

6. Phthalates

Yes

7. Short Chain Chlorinated Paraffins

Yes

8. Organchlorinated Compounds

Yes

9. IsoCyanates

Yes

10. Any Other

Yes

Chemicals Details (Currently on which you are working with Kassim Textiles Pvt Ltd)

Full Chemical Name	UOM	Package Type	Package Size	MSDS Available	TDS Available

Following Documents Received from Kassim Textile Pvt Limited and Below are my understandings.
(Please note that time to time Kassim Denim will provide updates of these as well as new ones for your information and re-confirmation of abding with it) Check if "YES"

	Received	Understands	Agree	Abide with it
GTW Inditex
MRSL Inditex
RTM Inditex
RSL C&A Policy
RSL Levis
RSL Levis (Highlights of Major changes)
RSL H&M Chemica Restrictions
RSL H&M Implementation Toolkit
RSL KONTOOR
RSL ALDI
RSL AAFA
RSL G-STAR
RSL Esprit
RSL Best Seller
RSL Tao
RSL E-LAND
RSL OKAIDI
RSL LIDL Chemical Restrictions
GreenScreen
ZDHC MRSL
KASSIM Textile Purchase Protocol Terms and Conditions

Remarks (if any)

I declared that all information provided in this form is true & based on factual figures to the best of my knowledge & belief. Further I also confirmed that I have understood & have accepted all the terms & Conditions & will keep following in future too.

Name

Designation

Date / Time

I have read and agree to the Terms and Conditions.