ADISA Certification Withdrawal

SECTION 1: CERTIFIED COMPANY INFORMATION
Company Name*
Approval Number*
Certification Scheme
Facility Address to be Withdrawn*
Please list the address of the facility to be withdrawn. Where multiple sites are to be withdrawn please use a separate form as each site has its own approval number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 if certified under Standard 8.0 UK.
PRINT NAME*

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

Request to Withdraw from an ADISA Certification Scheme.

Name	Job Title	Phone	e-mail