HIGG Audit Booking Form

Factory Name FEM Assessment ID Contact Name Position Phone Number E-mail Address Website Address Address

Factory Name Services Type / Audit Scope Address (same as per factory license)

Is Self-Assessment Completed? Select Yes No Completed Module Select Chemicals Management (Level 1) Chemicals Management (Level 2 and Level 3) Is this facility just cut to pack? Select Yes No Is this facility a light water user? Select Yes No Wastewater Treatment Plant Select On-site Off-site No Wet processes and chemicals onsite? Select Yes No Verified before? Select Yes No Verification/Audit Type Select Onsite Off site Methodology Select Announced Semi Announced Window Period Working Shift Total Number of Employees Tentative Date/Month of Verification Manufacturing Processes Signature & Confirmation of Applicant and Date