Notification Form FA5 
Established relationship between a supplemented food/property of supplemented food and a health effect

•	Notification of an established relationship between a supplemented food/property of supplemented food and a health effect must be made to the Director-General of the Ministry for Primary Industries under clause 1.4 and Table 1 of the New Zealand (Supplemented Food Standard) 2016, which incorporates Standard 1.2.7 of the Australia New Zealand Food Standards Code.
•	Send the completed notification form to the Ministry for Primary Industries at the above address. We prefer email files.
•	If there are any changes to the details provided in this notification after the notification has been submitted, you must promptly inform the Ministry for Primary Industries of the changes in writing.
•	Refer to the Privacy Act 1993 and Official Information Act 1982 notices at the end of this form regarding collection of information by the Ministry for Primary Industries.

1.	Full Legal Name of Notifier
Registered company name or partnership names (including the trading name) or individual name of notifier making general level health claim.
Attach a copy of the company name registration from the New Zealand Companies office (www.business.govt.nz/companies)	
     	

2.	Business Address and Contact Details 	
Street/Physical (location of actual premises)	Postal, including post code (for communication) 	
     
	     
	
Tel 	     	Mobile	     	
Fax	     	Email	     
By entering an email address you consent to being sent information and notifications electronically, if required.	

3.	Registered Company Address and Contact Details
Only complete if the notifier is a registered company and the registered office address is different from the physical/business address in section 3.	
Registered office
address	     	Tel	     	
		Fax	     	
4.	Established relationship between a supplemented food or property of supplemented food and health effect
State the food or property of food and health effect.
NB:	Claims not to be therapeutic in nature
	Claims not to compare vitamin or mineral content	

	

5.	Attachment of Certificate
The food business must certify that the food-health relationship has been established by a process of systematic review in accordance with Schedule 6 of Standard 1.2.7. This certification should be provided on company letterhead. If the food business is a body corporate, the certificate must be signed by a senior officer of the body corporate.	

	A certificate is attached which includes the following wording:
	I certify that the notified relationship between the supplemented food or property of supplemented food and health effect has 	been established by a process of systematic review that is described in Schedule 6 of the Australia New Zealand Food
               Standards Code, as incorporated into the New Zealand Food (Supplemented Food) Standard 2016.	

6.	Notifier Statement	
I confirm that:
1.	I am authorised to make this notification as the person with legal authority to act on behalf of the notifier; and
2.	The information supplied in this notification is truthful and accurate to the best of my knowledge; and
3.	I give consent for the information I have provided above to be made available on the MPI website* (www.mpi.govt.nz/food-safety)
4.	I agree that I am responsible for ensuring the information on the MPI website is current and correct, and will notify MPI promptly should any information change
* Note that the information may not necessarily be published on the MPI website.	
Name	     	Job Title	     	
Signature	     	Date	     	

7.	Final Checklist	
Have you:
  read and understood this form?
  filled this form in completely?
  attached a certificate (section 5)?
  read and signed the Notifier Statement (section 6)?	

Collection of Information 	

Collection of Personal Information 
Pursuant to Principle 3 of the Privacy Act 1993, we advise that:
•	This information is being collected for the purpose of notification of an established relationship between a supplemented food/property of supplemented food and a health effect under the New Zealand Food (Supplemented Food) Standard 2016; and  
•	The recipient of this information, which is the agency that will collect and hold the information, is the Ministry for Primary Industries, PO Box 2526, Wellington 6140; and 
•	Some of the information collected may be displayed on a public website; and
•	The collection of information is authorised under clause 1.4 of the New Zealand Food (Supplemented Food) Standard 2016, which incorporates Standard 1.2.7 and Schedule 6 of the Australia New Zealand Food Standards Code; and
•	The supply of this information is voluntary; and
•	Failure to provide the information means the health claim in relation to an established relationship between a supplemented food/property of supplemented food and a health effect under the New Zealand Food (Supplemented Food) Standard 2016 can not be made; and
•	Under Principles 6 and 7 of the Privacy Act 1993, you have the right of access to, and correction of, any personal information that you have provided.
Collection of Official Information
All information provided to the Ministry for Primary Industries is official information and may be subject to a request made under the Official Information Act 1982. 
If a request is made under that Act for information you have provided in this notification, the Ministry for Primary Industries will consider any such request, taking into account its obligations under the Official Information Act 1982 and any other applicable legislation.