Food Safety Supervisor Certificate Record

1. Business Details

Business Name: [Insert Legal Business Name] Trading Name (if different): [Insert Trading Name] Business Address: [Insert Street Address, Suburb, State, Postcode] Phone Number: [Insert Contact Phone Number] Email Address: [Insert Business Email]

2. Food Safety Supervisor Details

Full Name: [Insert Supervisor Full Name] Date of Birth: [DD/MM/YYYY] Job Title: [Insert Job Title] Employee ID (if applicable): [Insert ID Number]

3. Qualification Details

Registered Training Organisation (RTO) Name: [Insert RTO Name] RTO Code: [Insert RTO Code e.g. 12345] Statement of Attainment Number: [Insert Certificate Number] Date of Issue: [DD/MM/YYYY] Date of Expiry: [DD/MM/YYYY]

Relevant Units of Competency Completed:

• Use hygienic practices for food safety (SITXFSA005)
• Participate in safe food handling practices (SITXFSA006)
• Participate in safe food handling practices for transport and distribution (SITXINV006)
• Other: [Insert Unit Code and Name]

4. Industry Sector

Please select the sector relevant to this business:

• Retail and Hospitality (e.g. Restaurants, Cafes, Takeaways)
• Community and Health Services (e.g. Nursing Homes, Childcare)
• Food Processing (e.g. Manufacturers, Packers)

5. Declaration

I declare that the information recorded above is true and correct. I understand that this certificate must be kept on the business premises at all times and produced for inspection by an authorised officer upon request.

Signature of Food Safety Supervisor: __________________________ Date: __________________________

Signature of Business Owner/Proprietor: __________________________ Date: __________________________

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Keep this record in a safe and accessible location on the business premises.