FORMULAIRE

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QUESTIONNAIRE Bel I: PRELIMINARY INFORMATION

DATE: June 11, 2014

SUPPLIER’S NAME: Danisco Czech Republic
INGREDIENT’S NAME: GRINDSTED® Pectin AMD 383, 810572.03
BEL INGREDIENT CODE:

CERTIFICATION

HALAL:

YES X NO  IF YES, PLEASE ENCLOSE THE CERTIFICATE

IF NO:
- Does the product contain an ingredient of animal origin? YES  NO 

o If yes which and what animal?

- Does the product contain an ingredient of human origin? YES  NO 

o If yes which?

- Does the product contain an ingredient derived from insect? YES  NO 

o If yes which?

- Does the product contain alcohol or is it made from ingredient containing alcohol?

YES  NO 

- Does the product contain blood? YES  NO 

KOSHER:

YES X NO  (IF YES, PLEASE ENCLOSE THE CERTIFICATE)

 ALLERGENS CERTIFICATE

Important note: this certificate is required for our global exports, some details go beyond
European regulation (for example, exemptions).

INTENTIONAL if yes, specify if yes, specify

Allergenic substances ADDITION the nature the level in the
(or products thereof which contain some proteins) (seed, oil,
YES NO starch…) finished product
i
Cereals containing gluten and products thereof,
X
including glucose syrups, dextrose, maltodextrins…

Crustaceans and products thereof X

Eggs and products thereof X
Fish and products thereof, including fish gelatine X
Peanuts and products thereof X(1)
Soybeans and products thereof, including fully refined
X
oil and fat, tocopherols, phytosterols…
Milk and products thereof (including lactose)
- from cow X
- from goat X
- from sheep X
ii
Nuts and products thereof X

Celery and products thereof X

Mustard and products thereof X
Sesame seeds and products thereof X
Sulphites at concentration of more than 10 mg/kg or
X
10 mg/l expressed as SO2
Lupine and products thereof X
Molluscs and products thereof X
Buckwheat X
Beef X
Pork X
Chicken (poultry) X
Gelatine X
Apples X
Oranges X Pectin 80%
Kiwifruit X

i
i.e. wheat, rye, barley, oats, spelt, kamut or their hybridised strains.
ii
i.e. Almond, Hazelnut, Walnut, Cashew, Pecan nut, Brazil nut, Pistachio nut, Macadamia nut and Queensland nut.
 INTENTIONAL if yes, specify if yes, specify
Allergenic substances ADDITION the nature the level in the
(or products thereof which contain some proteins) (seed, oil,
YES NO starch…) finished product

Yams (ignames) X
“Matsutake” Mushrooms X
Peaches X
Banana X
Tomatoes X
Bee pollen X
Propolis X

Royal jelly X

(1) If no intentional addition of peanuts and products thereof, please fill the following table:

YES
NO
(specify the nature : seed, oil)
accidental presence of peanuts and peanut products X
if yes, because of presence in your factory

if yes, by contamination at your suppliers

../..
In addition, the Swiss Ordinance of Federal Department of Home Affairs on the labelling and
advertisement of foodstuffs (OEDAI of 23/11/2005) requires the labelling of the allergenic
substances even when their presence is non-intentional. Thank you for indicating if this situation
can occur for the product concerned by this certificate.

Accidental presence of : yes no If yes : Level ?

Sulphites at concentration more than X

10 mg SO2 / kg (or l)

Cereals (gluten) at concentration more

than 10 mg of prolamin (gliadin) / 100 g
dry matter X

Other allergens at concentration more X

than 0.1%

For all the guarantees in this certificate, the supplier commits himself making the same checks at
the time of any modification of some ingredients, additives or processing aids, and for any
development of new products.
The supplier also commits himself warning us of any modification which would be likely to modify
the guarantees given above.

Date: Stamp and Signature:

June 11, 2014 Rudi Zaupper

Product Service Manager