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This section applies to persons who have previously attained an FSS certificate within the last 5 years but need their FSS certificate to be reissued by the NSW Food Authority. Fill in the form below and return it with payment to Certificate identification number if known Place of training State or Territory Section 3 Authorisation and payment Applicant authorisation I acknowledge and understand that the NSW Food Authority will use the information contained within this application for the purposes of determining my request to be issued a Food Safety Supervisor certificate. Food Safety Supervisor Program FSS certificate request form FSS 003 Is this a New request for an FSS certificate go to Section 1 Reissue of an existing FSS certificate that was originally issued by an RTO go to Section 2 Reissue of a lost FSS certificate that was originally issued by an RTO that no longer exists or is no longer approved go to Section 2 Section 1 New request To be eligible for an FSS certificate you must meet one of the criteria listed below please tick appropriate box of the required units were attained from any RTO in Australia prior to 31 August 2010 and within five All years from date of request go to Section 1a. eg Cert IV Commercial Cookery within five years from date of request go to Section 1b. training was delivered in person only face-to-face at a location outside of NSW after 31 August 2010 and within five years from date of request go to Section 1c. Some of the required units were attained prior to 31 August 2010 and within five years from date of request from an RTO registered in NSW* The other units were attained after 31 August 2010 from an interstate RTO not registered in NSW where the training was delivered in person only face-to-face at a location outside of NSW go to Section 1d. The unit FDFFS2001A Implement the food safety program and procedures was attained from any RTO in Australia prior to 31 August 2010 and within five years from date of request go to Section 1e. in Australia as a completed vocational qualification in Food Processing within five years from date of request go to Section 1e. Note Units attained after 31 August 2010 from an RTO registered in NSW but not approved to conduct training under this program will not be recognised for an FSS certificate unless exceptional circumstances are accepted by the Authority. Fill in the relevant sections on the following pages and return it with payment to NSW Food Authority PO Box 6682 Silverwater NSW 1811 NSW/FA/FI081/1305 Page 1 of 8 Section 1a Attained units anywhere in Australia prior to 31 August 2010 and within five years from date of request Full name Postal address Suburb Postcode Email Phone number Mobile number RTO name RTO location NSW Qld Vic ACT Tas SA NT WA Date units were attained see date on your Statement of Attainment Units of competency attained Follow workplace hygiene procedures SITXOHS002A Implement food safety procedures SITXFSA001A Apply retail food safety practices SIRRFSA001A P lease provide a certified copy of your Statement s of Attainment Qualification if applicable Note A certified copy is a photocopy which has been compared with the original and endorsed as a true copy by a Justice of the Peace JP or a public officer such as a police officer.
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