Healthier Choice Label Programme - DOC - DOC

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                                                                                                 FORM hc-B



Healthier Choice Label Programme- Healthier Choice Symbol


This form may take you 5 minutes to fill in.

                                                APPLICATION FORM

  NAME OF REGISTERED COMPANY: ___________________________________________

  REGISTERED ADDRESS: ______________________________________________________

  ____________________________________________________________________________

  TELEPHONE: _______________________                              FACSIMILE: _____________       _________

  CONTACT PERSON: __________________________________________________________

  DESIGNATION: _______________________________________________________________

  EMAIL ADDRESS:


  NUMBER OF PRODUCT(S) APPLIED: ____________________________________________
  (Please complete one Product Information Form for each product applied)


  SIGNATURE: ______________________________________

  DATE: ______________________________                                           COMPANY STAMP


  Please provide information for Licence Agreement preparation:

  1. Name of Bearer (Mr./Ms./Mrs./Mdm/Dr)*:                               <at least a Manager>

  Designation:                                                    Telephone: _______________________

  Email Address:

  2. Name of Witness:                                                     NRIC no.:

  * Please delete where applicable

PLEASE FORWARD COMPLETED APPLICATION FORM, PRODUCT INFORMATION FORM(S) AND NUTRIENT ANALYSIS
REPORT(S) TO:

                                              HEALTH PROMOTION BOARD
                                     ADULT HEALTH DIVISION, NUTRITION DEPT (LEVEL 4)
                                              3 SECOND HOSPITAL AVENUE
                                                 SINGAPORE 168937
                                                   FAX: 6438 3609

                                          EMAIL: hpb_nutrition_dept@hpb.gov.sg



                                                                                                        HCLP- 1
                                                                                                    FORM hc-B



Healthier Choice Label Programme- Healthier Choice Symbol


                                     PRODUCT INFORMATION FORM

PRODUCT NAME: ________________________________________________________
                                                                                        PRODUCT CATEGORY:
                                                                                        (please tick one)
PLACE OF MANUFACTURE: ______________________________________________
                                                                                        Healthier Choice Symbol
DESCRIPTION OF PRODUCT: _____________________________________________
                                                                                         DAIRY PRODUCTS
________________________________________________________________________                 CEREALS
                                                                                         LEGUMES
INGREDIENTS: _________________________________________________________                   VEGETABLES
                                                                                         FRUITS
________________________________________________________________________                 SEAFOODS
                                                                                         MEAT & POULTRY
PACKAGE SIZE(S) AVAILABLE: __________________________________________                    EGGS
                                                                                         FATS & OILS
                                                                                         MISCELLANEOUS

NUTRIENT VALUES (per 100g):

ENERGY (kcal): _________________________

PROTEIN (g): ___________________________

TOTAL FAT (g): ________________________

SATURATED FAT (g): ___________________

TRANS FAT (g):

CHOLESTEROL (mg): ____________________

CARBOHYDRATE (g): ___________________

SUGAR (g):                                                    _________________________________
                                                                  COMPANY STAMP & DATE
DIETARY FIBRE (g): _____________________

SODIUM (mg): __________________________


 Note: Please provide nutrient analysis report for the values declared.
The nutrient analysis report must be done by an independent laboratory using approved methods, for example those
accepted by the Association of Official Analytical Chemists (AOAC).



For Office Use
      [ ] Approved
      [ ] Not Approved. Reason:

      Signature: ______________________                      Date: _____________________




                                                                                                         HCLP- 2