to Audit/Surveillance visit report no.:		

No.	Description 
of the non-conformity and 
the agreed corrective action	Appointment to provide proof of rectifying the non-conformity	Date of acceptance of corrective action	
1				
2				
3				
4				
5				
6				
7				
The above statements are confirmed by					Place/Date	Signature
assessor	Place/Date	Signature representative of the company	Decision of the auditor/surveillance assessor regarding fulfilment of the corrective actions	
The corrective actions were completely fulfilled.	
		Place/Date	Signature assessor