Supplier Verification Form

Dear Valued Supplier,

POET Nutrition is committed to the safety and quality of our supply chain. In accordance with the rules set forth by the Food Safety Modernization Act, POET has implemented a fully functional food safety system. As a component of this system, we have established a need to validate the food safety compliance and controls of our suppliers of raw materials and finished goods to POET Nutrition.

Please review and complete the information below. Direct any questions via email to Brian Heikes (Brian.Heikes@POET.COM) and Clark Schultz (Clark.Schultz@POET.com).

Supplier Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Country:

select

Plant Quality Contact:

Phone:

Email:

Cell Phone:

Supplier Primary Contact:

Phone:

Email:

Cell Phone:

Please answer the following questions with regard to the products supplied to POET Nutrition by your company.

List of Products Supplied:

Supply Location Address 1:

Address 2:

City:

State:

Zip Code:

Country:

select

Does your facility have in place a fully functional food safety plan including a hazard analysis?

select

Does your facility operate and follow a cGMP program that is audited routinely for compliance to the program standards?

select

Do you have a bio security program in place?

select

Does a recall program exist?

select

If so, how often is it tested for effectiveness?

Are your employees trained in your cGMP and other relevant food safety and security programs?

select

Do you have a master sanitation program in place?

select

Do you have a supplier/vendor approval program in place?

select

Do you have a functioning pest control program in place?

select

Does your facility have a lot control and traceability program in compliance with the Bioterrorism Act of 2002?

select

If so, please describe the lot code:

BSE Compliance Statement

I/We certify that all products and/or ingredients sold to POET Nutrition, Inc. do NOT contain Prohibited Meat and Bone Meal as defined by FDA Regulation 21 CFR 589.2000/2001. I/We certify that the facility shipping product to POET Nutrition, Inc. does not handle or use Prohibited Mammalian Meat and Bone Meal or products containing the prohibited material. I/We certify that cross contamination did not take place during processing, storage and shipment of our products. I/We certify that all outbound conveyances are inspected to ensure they are clean and free of residual material or that the previous past cargo was compliant with the above BSE guarantee. I/We further certify that this letter will cover all future shipments until written notice has been provided.

Person Completing Form and Certifying BSE Statement: *

Title: *

Signature: *

By typing in your name you are certifying the BSE Statement
Date: