工業(yè)產(chǎn)品生產(chǎn)許可證

年度監(jiān)督審查企業(yè)自查申報表

（200 年度）

產(chǎn)品名稱：__________________________________

企業(yè)名稱：__________________________________

企業(yè)代碼：__________________________________

詳細(xì)地址：__________________________________

郵政編碼：__________________________________

聯(lián) 系 人：__________________________________

聯(lián)系電話：__________________________________

填報日期： 年        月        日

全國工業(yè)產(chǎn)品生產(chǎn)許可證辦公室印制

— 1 —

填表說明：

1、填寫要實(shí)事求是，不得弄虛作假；

2、申請書一律用鋼筆填官，字跡清晰、工整、不得涂改，也可以打印；

3、企業(yè)名稱要與生產(chǎn)許可證證書上的企業(yè)名稱一致；

4、產(chǎn)品名稱按《實(shí)施細(xì)則》規(guī)定的名稱填寫；

5、年產(chǎn)量、產(chǎn)值、銷售額、繳稅額、利潤均按上年度填寫；

6、填寫附表時如空間不夠，可自行附頁；

7、申請書封面必須加蓋企業(yè)公章；

8、該表一式二份（企業(yè)公章復(fù)印無效）。

— 2 —

企業(yè)基本情況年變化一覽表

獲證時企業(yè)名稱
現(xiàn)企業(yè)名稱
獲證時企業(yè)生產(chǎn)場地地址
現(xiàn)企業(yè)生產(chǎn)場地地址
獲證時法人代表		現(xiàn)法人代表
經(jīng)濟(jì)性質(zhì)		現(xiàn)經(jīng)濟(jì)性質(zhì)
獲證時上級主管單位		現(xiàn)上級主管單位
獲證時營業(yè)執(zhí)照編號		現(xiàn)營業(yè)熱照編號
獲證時企業(yè)代碼		現(xiàn)企業(yè)代碼
獲證時企業(yè)總?cè)藬?shù)		現(xiàn)企業(yè)總?cè)藬?shù)
獲證時企業(yè)技術(shù)人員數(shù)		現(xiàn)企業(yè)技術(shù)人員數(shù)
獲證時占地面積	米2	現(xiàn)占地面積
獲證時建筑面積	米2	現(xiàn)建筑面積
獲證時固定資產(chǎn)	萬元	現(xiàn)固定資產(chǎn)	萬元
獲證時流動資金	萬元	現(xiàn)流動資金	萬元
年總產(chǎn)值	萬元	年銷售額	萬元
年繳稅金額	萬元	年利潤	萬元

— 3 —

企業(yè)主要負(fù)責(zé)人、工程技術(shù)骨干人員一覽表

序  號	姓  名	性  別	年  齡	職  務(wù)	職  稱	文化程度	專  業(yè)	工作崗位

— 4 —

主要生產(chǎn)設(shè)備、工裝明細(xì)表

序號	名        稱	規(guī)格型號	數(shù) 量	完好狀態(tài)	使用場所	生 產(chǎn) 廠 及 國 別	生產(chǎn)日期	購置日期

— 5—

主要檢測設(shè)備明細(xì)表

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序號	名        稱	規(guī)格型號	數(shù) 量	完好狀態(tài)	使用場所	生 產(chǎn) 廠 及 國 別	生產(chǎn)日期	購置日期
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{placeholder tag=td i=2425} {placeholder tag=p i=448} {placeholder tag=span i=1440}生   產(chǎn)   單   位

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{placeholder tag=td i=2777} {placeholder tag=p i=815} {placeholder tag=span i=1817}

{placeholder tag=td i=2778} {placeholder tag=p i=816} {placeholder tag=span i=1818}

{placeholder tag=td i=2779} {placeholder tag=p i=817} {placeholder tag=span i=1819}

{placeholder tag=p i=818} {placeholder tag=span i=1820}

{placeholder tag=p i=819} {placeholder tag=span i=1821} — 1{placeholder tag=span i=1822}1{placeholder tag=span i=1823} —

{placeholder tag=p i=820} {placeholder tag=span i=1824}企業(yè)工業(yè)產(chǎn)品生產(chǎn)許可證年審自查表

{placeholder tag=p i=821} {placeholder tag=span i=1825}

{placeholder tag=p i=822} {placeholder tag=span i=1826}企業(yè)名稱（蓋章）：　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　填表日期：　　　年　月　日

{placeholder tag=table i=2029} {placeholder tag=td i=2780} {placeholder tag=p i=823} {placeholder tag=span i=1827}年審項(xiàng)目條款號

{placeholder tag=td i=2781} {placeholder tag=p i=824} {placeholder tag=span i=1828}年　審　項(xiàng)　目

{placeholder tag=td i=2782} {placeholder tag=p i=825} {placeholder tag=span i=1829}企業(yè)自查記錄

{placeholder tag=td i=2783} {placeholder tag=p i=826} {placeholder tag=span i=1830}符合性說明

{placeholder tag=td i=2784} {placeholder tag=p i=827} {placeholder tag=span i=1831}自查人簽名

{placeholder tag=td i=2785} {placeholder tag=p i=828} {placeholder tag=span i=1832}1

{placeholder tag=td i=2786} {placeholder tag=p i=829} {placeholder tag=span i=1833}企業(yè)生產(chǎn)是否正常，有無連續(xù)一年以上停產(chǎn)或已轉(zhuǎn)產(chǎn)的情況

{placeholder tag=td i=2787} {placeholder tag=p i=830} {placeholder tag=span i=1834}

{placeholder tag=td i=2788} {placeholder tag=p i=831} {placeholder tag=span i=1835}

{placeholder tag=td i=2789} {placeholder tag=p i=832} {placeholder tag=span i=1836}

{placeholder tag=td i=2790} {placeholder tag=p i=833} {placeholder tag=span i=1837}2

{placeholder tag=td i=2791} {placeholder tag=p i=834} {placeholder tag=span i=1838}企業(yè)生產(chǎn)條件是否符合發(fā)證時的條件，有無嚴(yán)重不符合的情況

{placeholder tag=td i=2792} {placeholder tag=p i=835} {placeholder tag=span i=1839}

{placeholder tag=td i=2793} {placeholder tag=p i=836} {placeholder tag=span i=1840}

{placeholder tag=td i=2794} {placeholder tag=p i=837} {placeholder tag=span i=1841}

{placeholder tag=td i=2795} {placeholder tag=p i=838} {placeholder tag=span i=1842}3

{placeholder tag=td i=2796} {placeholder tag=p i=839} {placeholder tag=span i=1843}企業(yè)質(zhì)量體系運(yùn)行是否正常、有效，有無較嚴(yán)重的管理滑坡、生產(chǎn)條件改變、質(zhì)量標(biāo)準(zhǔn)降低現(xiàn)象

{placeholder tag=td i=2797} {placeholder tag=p i=840} {placeholder tag=span i=1844}

{placeholder tag=td i=2798} {placeholder tag=p i=841} {placeholder tag=span i=1845}

{placeholder tag=td i=2799} {placeholder tag=p i=842} {placeholder tag=span i=1846}

{placeholder tag=td i=2800} {placeholder tag=p i=843} {placeholder tag=span i=1847}4

{placeholder tag=td i=2801} {placeholder tag=p i=844} {placeholder tag=span i=1848}企業(yè)有無變更名稱，是否按規(guī)定辦理生產(chǎn)許可證更名手續(xù)

{placeholder tag=td i=2802} {placeholder tag=p i=845} {placeholder tag=span i=1849}

{placeholder tag=td i=2803} {placeholder tag=p i=846} {placeholder tag=span i=1850}

{placeholder tag=td i=2804} {placeholder tag=p i=847} {placeholder tag=span i=1851}

{placeholder tag=td i=2805} {placeholder tag=p i=848} {placeholder tag=span i=1852}5

{placeholder tag=td i=2806} {placeholder tag=p i=849} {placeholder tag=span i=1853}企業(yè)有無遷址、增設(shè)生產(chǎn)場點(diǎn)或者生產(chǎn)條件發(fā)生較大變化，是否已辦理生產(chǎn)許可證變更手續(xù)

{placeholder tag=td i=2807} {placeholder tag=p i=850} {placeholder tag=span i=1854}

{placeholder tag=td i=2808} {placeholder tag=p i=851} {placeholder tag=span i=1855}

{placeholder tag=td i=2809} {placeholder tag=p i=852} {placeholder tag=span i=1856}

{placeholder tag=p i=853} {placeholder tag=span i=1857} — {placeholder tag=span i=1858}12{placeholder tag=span i=1859} —

{placeholder tag=p i=854} {placeholder tag=span i=1860}企業(yè)工業(yè)產(chǎn)品生產(chǎn)許可證年審自查表     （續(xù)）

{placeholder tag=p i=855} {placeholder tag=span i=1861}企業(yè)名稱（蓋章）：                                                                   填表日期：   年   月    日

{placeholder tag=table i=2030} {placeholder tag=td i=2810} {placeholder tag=p i=856} {placeholder tag=span i=1862}年審項(xiàng)目條款號

{placeholder tag=td i=2811} {placeholder tag=p i=857} {placeholder tag=span i=1863}年審項(xiàng)目

{placeholder tag=td i=2812} {placeholder tag=p i=858} {placeholder tag=span i=1864}企業(yè)自查記錄

{placeholder tag=td i=2813} {placeholder tag=p i=859} {placeholder tag=span i=1865}符合性說明

{placeholder tag=td i=2814} {placeholder tag=p i=860} {placeholder tag=span i=1866}自查人簽字

{placeholder tag=td i=2815} {placeholder tag=p i=861} {placeholder tag=span i=1867}6

{placeholder tag=td i=2816} {placeholder tag=p i=862} {placeholder tag=span i=1868}獲證產(chǎn)品有無增加單元、擴(kuò)增規(guī)格，是否已辦理生產(chǎn)許可證變更手續(xù)

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{placeholder tag=td i=2818} {placeholder tag=p i=864} {placeholder tag=span i=1870}

{placeholder tag=td i=2819} {placeholder tag=p i=865} {placeholder tag=span i=1871}

{placeholder tag=td i=2820} {placeholder tag=p i=866} {placeholder tag=span i=1872}7

{placeholder tag=td i=2821} {placeholder tag=p i=867} {placeholder tag=span i=1873}獲證產(chǎn)品是否已按規(guī)定標(biāo)明生產(chǎn)許可證標(biāo)記和編號

{placeholder tag=td i=2822} {placeholder tag=p i=868} {placeholder tag=span i=1874}

{placeholder tag=td i=2823} {placeholder tag=p i=869} {placeholder tag=span i=1875}

{placeholder tag=td i=2824} {placeholder tag=p i=870} {placeholder tag=span i=1876}

{placeholder tag=td i=2825} {placeholder tag=p i=871} {placeholder tag=span i=1877}8

{placeholder tag=td i=2826} {placeholder tag=p i=872} {placeholder tag=span i=1878}獲證產(chǎn)品在市級上質(zhì)量監(jiān)督檢查中，有無不合格的情況

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{placeholder tag=td i=2828} {placeholder tag=p i=874} {placeholder tag=span i=1880}

{placeholder tag=td i=2829} {placeholder tag=p i=875} {placeholder tag=span i=1881}

{placeholder tag=td i=2830} {placeholder tag=p i=876} {placeholder tag=span i=1882}9

{placeholder tag=td i=2831} {placeholder tag=p i=877} {placeholder tag=span i=1883}企業(yè)有無其他列入生產(chǎn)許可證管理但未獲證的產(chǎn)品

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{placeholder tag=td i=2833} {placeholder tag=p i=879} {placeholder tag=span i=1885}

{placeholder tag=td i=2834} {placeholder tag=p i=880} {placeholder tag=span i=1886}

{placeholder tag=td i=2835} {placeholder tag=p i=881} {placeholder tag=span i=1887}10

{placeholder tag=td i=2836} {placeholder tag=p i=882} {placeholder tag=span i=1888}企業(yè)有無涂改、轉(zhuǎn)讓生產(chǎn)許可證、生產(chǎn)假冒偽劣產(chǎn)品或其他質(zhì)量違法行為

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{placeholder tag=td i=2838} {placeholder tag=p i=884} {placeholder tag=span i=1890}

{placeholder tag=td i=2839} {placeholder tag=p i=885} {placeholder tag=span i=1891}

{placeholder tag=td i=2840} {placeholder tag=p i=886} {placeholder tag=span i=1892}11

{placeholder tag=td i=2841} {placeholder tag=p i=887} {placeholder tag=span i=1893}產(chǎn)品質(zhì)量檢驗(yàn)報告或檢驗(yàn)記錄數(shù)據(jù)與《實(shí)施細(xì)則》中相關(guān)標(biāo)準(zhǔn)的符合性

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{placeholder tag=td i=2843} {placeholder tag=p i=889} {placeholder tag=span i=1895}

{placeholder tag=td i=2844} {placeholder tag=p i=890} {placeholder tag=span i=1896}

{placeholder tag=p i=891} {placeholder tag=span i=1897} — {placeholder tag=span i=1898}13{placeholder tag=span i=1899} —

{placeholder tag=p i=892} {placeholder tag=span i=1900}工業(yè)產(chǎn)品生產(chǎn)許可證獲證企業(yè)年度監(jiān)督審查報告

{placeholder tag=table i=2031} {placeholder tag=td i=2845} {placeholder tag=p i=893} {placeholder tag=span i=1901}企業(yè)名稱

{placeholder tag=td i=2846} {placeholder tag=p i=894} {placeholder tag=span i=1902}

{placeholder tag=td i=2847} {placeholder tag=p i=895} {placeholder tag=span i=1903}企業(yè)地址

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{placeholder tag=td i=2849} {placeholder tag=p i=897} {placeholder tag=span i=1905}產(chǎn)品名稱

{placeholder tag=td i=2850} {placeholder tag=p i=898} {placeholder tag=span i=1906}

{placeholder tag=td i=2851} {placeholder tag=p i=899} {placeholder tag=span i=1907}郵  編

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{placeholder tag=td i=2853} {placeholder tag=p i=901} {placeholder tag=span i=1909}電話

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{placeholder tag=td i=2855} {placeholder tag=p i=903} {placeholder tag=span i=1911}申證產(chǎn)品名稱

{placeholder tag=td i=2856} {placeholder tag=p i=904} {placeholder tag=span i=1912}

{placeholder tag=td i=2857} {placeholder tag=p i=905} {placeholder tag=span i=1913}聯(lián)系人

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{placeholder tag=td i=2859} {placeholder tag=p i=907} {placeholder tag=span i=1915}傳真

{placeholder tag=td i=2860} {placeholder tag=p i=908} {placeholder tag=span i=1916}

{placeholder tag=tr i=2903} {placeholder tag=td i=2861} {placeholder tag=p i=909} {placeholder tag=span i=1917}企業(yè)

{placeholder tag=p i=910} {placeholder tag=span i=1918}自查

{placeholder tag=p i=911} {placeholder tag=span i=1919}結(jié)論

{placeholder tag=td i=2862} {placeholder tag=p i=912} {placeholder tag=span i=1920} 根據(jù)《工業(yè)產(chǎn)品生產(chǎn)許可證年度監(jiān)督審查管理規(guī)定》和《________________產(chǎn)品生產(chǎn)許可證換（發(fā)）證實(shí)施細(xì)則》，本企業(yè)于________年_______月______日至______年______月______日對生產(chǎn)條件進(jìn)行了自查。經(jīng)審查本企業(yè)在上一年度內(nèi)有如下不符合：

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{placeholder tag=p i=914} {placeholder tag=span i=1922}

{placeholder tag=p i=915} {placeholder tag=span i=1923}

{placeholder tag=p i=916} {placeholder tag=span i=1924} 經(jīng)綜合評價，本審查組對該企業(yè)的年審結(jié)論是：_____________________。

{placeholder tag=td i=2863} {placeholder tag=p i=917} {placeholder tag=span i=1925}企業(yè)負(fù)責(zé)人簽署意見

{placeholder tag=tr i=2904} {placeholder tag=td i=2864} {placeholder tag=p i=918} {placeholder tag=span i=1926}

{placeholder tag=p i=919} {placeholder tag=span i=1927}

{placeholder tag=p i=920} {placeholder tag=span i=1928}

{placeholder tag=p i=921} {placeholder tag=span i=1929}

{placeholder tag=p i=922} {placeholder tag=span i=1930}

{placeholder tag=p i=923} {placeholder tag=span i=1931}企業(yè)負(fù)責(zé)人簽字（蓋章）

{placeholder tag=p i=924} {placeholder tag=span i=1932} 年   月   日

{placeholder tag=tr i=2905} {placeholder tag=td i=2865} {placeholder tag=p i=925} {placeholder tag=span i=1933}省級許可證辦公室年審竟見

{placeholder tag=td i=2866} {placeholder tag=p i=926} {placeholder tag=span i=1934}

{placeholder tag=p i=927} {placeholder tag=span i=1935}

{placeholder tag=p i=928} {placeholder tag=span i=1936}

{placeholder tag=p i=929} {placeholder tag=span i=1937}

{placeholder tag=p i=930} {placeholder tag=span i=1938} 年    月    日（蓋章）

{placeholder tag=tr i=2906} {placeholder tag=td i=2867} {placeholder tag=td i=2868} {placeholder tag=td i=2869} {placeholder tag=td i=2870} {placeholder tag=td i=2871} {placeholder tag=td i=2872} {placeholder tag=td i=2873} {placeholder tag=p i=931} {placeholder tag=span i=1939}申證產(chǎn)品名稱填寫：產(chǎn)品名稱，用圓括弧注明申證單元，如食品電烤爐（商用電烤爐，商用旋轉(zhuǎn)爐2單元）。

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