Gluten-Free Product Ingredient Declaration Form
Product Information
Product Name
Manufacturer
Product Code/ID
Date
Ingredient List
Ingredient Name
Source
Function (e.g., thickener, sweetener)
Contains Gluten? (Yes/No)
Allergen Statement
List any allergens present (including wheat or gluten)
Production Facility
Is the product made in a dedicated gluten-free facility? (Yes/No)
Describe the measures taken to prevent gluten cross-contact
Declaration
Completed by (Name)
Title/Position