Gluten Free Manufacturing Model, http://www.nuchiafoods.com

1. Manufacturing Gluten-Free Foods Jay Berger Miss Roben’s, Inc. AKA The Allergy Grocer

6. Product/Ingredient Name: ________________________________________ UPC Code #_______________________________ Contact Person, Title, & Phone #: _____________________________________ Is the ingredient/product produced & packaged in the same facility? ___Yes __ No If it is packaged at another facility, please make a copy of this form to mark & complete it for the conditions where it is packaged. Please use Yes or No statements where appropriate & identify specifics wherever possible (e.g. soy-lecithin, dairy-cream, nuts-whole cashews, further details etc) where applicable. Allergen Present in same plant? If yes, in the same room? Present in product? Are any ingredients used in product derived from this? Used as a processing aid for this product? In plant & manufactured on same line? In plant & manufactured on same day? Gluten (includes wheat, oats, rye, barley) Dairy (includes lactose, whey, casein) Soy (lecithin, oil, protein)

7. Do you test for Wheat? ___Yes ___No If yes, what PPM is it tested to? Do you test for Gluten? ___Yes ___No If yes, what PPM is it tested to? Do you test for Peanuts? ___Yes ___No If yes, what PPM is it tested to? Do you test for Tree Nuts? ___Yes ___No If yes, what PPM is it tested to? Do you test for Eggs? ___Yes ___No If yes, what PPM is it tested to? Do you test for Dairy? ___Yes ___No If yes, what PPM is it tested to? If used, is your baking powder aluminum-free? ___Yes ___No Is your product/ingredient certified Kosher? If so which certification does it hold? Is your product/ingredient Organic? What is the shelf life of this product/ingredient? Describe your cleaning procedures & other methods for allergen avoidance in processing & packaging? _________________________________________________________________________________ ____________________________________________________________________________________ ___________________________________________________________________________________ Is there anything else we should know to better help us? _________________________________________________________________________________ ____________________________________________________________________________________ ___________________________________________________________________________________