ADISA Certification Withdrawal

SECTION 1: CERTIFIED COMPANY INFORMATION
Company Name*
Approval Number*
Facility Address to be Withdrawn*
Please list the address of the facility to be withdrawn. Where multiple sites are to be withdrawn please use a separate form as each site has its own approval number
SECTION 2: CONTACT INFORMATION
Person making withdrawal request*
Name Job Title Phone e-mail
SECTION 3: WITHDRAWAL REASONS
Please provide details on the reason for withdrawal.*
Please provide date withdrawal is required.*
Confirmation of understanding.*
- Confirm understanding of withdrawal.
* I must cease the use of the certification mark.
* I must make no further reference to certification.
* I must inform data controller or data processors of the withdrawal in all instances where certification was stated during the engagement process.
* Please note that ADISA will notify the ICO about the withdrawal.
The membership fee will become due to join the onboarding program but your membership renewal fees will be due annually on the date of your final audit.
PRINT NAME*

Please print your name as a signature to confirm your request.

Request to Withdraw from ADISA Certification Scheme

Name	Job Title	Phone	e-mail