COMPANY CODE:	DATE OF APPLICATION:
COMPANY NAME:	PRODUCT NAME:

NUMBER OF CERTIFICATES:	ONE CERTIFICATE PER TANK	ONE CERTIFICATE FOR ALL TANKS
PRODUCT SHIPPED
QUANTITY SHIPPED
MANUFACTURER NAME
KOSHER STATUS	PAREVE NON-PASSOVER	DAIRY CHOLOV AKUM	PAREVE PASSOVER	PASSOVER (KITNIYOT)
LOADING LOCATION	LOADING DATE
SHIPPING DOCUMENT	SHIPPING DATE
TANK NUMBER MORE TANKS IN ADDENDUM
SEAL NUMBERS
CLEANING CERTIFICATE
CERTIFICATE DATE
PREVIOUS LOAD 1
PREVIOUS LOAD 2
PREVIOUS LOAD 3

Please note that the tanker kosher certificate will ONLY be issued after KLBD approval of the three previous loads and after the cleaning certificate is sent to KLBD. Some previous loads will require additional information, e.g. feedstock or an MSDS with the feedstock listed will always be required for the following: ethanol, fruit juices, fatty acids, glycerine, triacetin and vinegar.

This list is indicative and not exclusive. A more complete list of products not approved for previous loads is available in a separate document. If the load being sent is Kosher for Passover, then there will be additional restrictions on previous loads.

REQUESTED BY	PHONE NUMBER
EMAIL ADDRESS	FAX NUMBER

Please email this completed form in to tankers@klbdkosher.org, along with all relevant documentation.

For help with completing this form, please refer to the Guidance Notes Document or call +44 (0) 20 8343 5853.