You are on page 1of 3

4 , 2014 , /

RAVI DWIVEDI 8871861199,8827460280


Office Address (Authorized licensee) Cyberedge Infoserve 23/348,Nr. Hanuman mandir Amahi a !e"a 48#$$% &ontact'(#3$%)8%%%,*8*(44*888,$*##2422%)$

Form "A" [See Regulation 2.1.1 and Regulation 2.1.7]

Application for Registration under Food Safety and Standards Act, 2006
Application No: Name of Applicant / Company : Kind of Business : Designation : 20140100300024606 jahnvi kirana store Retailer kirana Individual

Address of Premises where food business is located


indane gas godown ke samne gram maidani distt rewa State : Madh a !radesh District : Rewa Address :

Correspondence Address etails


indane gas godown ke samne gram maidani distt rewa State : Madh a !radesh District : Rewa Sub: "u#ur Address :

Sub: "u#ur Division Village : Maidani in : 4$6001 Code

Division Village : %/& in : 4$6001 Code

Contact
!el No #a$ No Contact erson

etails
: %& : %& : +rijendra mani singh "obile : '($46003)( No %mail : * +eredge,-gmail.*om

!ther

etails

&n case of Ne' business ( intended date of start : 04/01/2014 "n case of Sessional business# State the opening and closing period of the January-December $ear % Source of &ater Suppl$ % Sanction 'lectricit$ (oad or )P *sed % *pload Photo % *pload ocument for "dentit$ Proof +eg% Ration Card# ,oter " Card etc.Public NA RGPHID321737.jpeg PAN Car RGID321737.jpeg

escription of the food items proposed to be manufactured or sold%


Sl. .o. 1 2 3 4 ( .ame of the food categor$ !1 - Dairy pr" uc#$ an anal"gue$% e&clu ing pr" uc#$ "' '"" ca#eg"ry !2.! 16 / !re0ared 1oods 1( - Rea y-#"-ea# $a)"urie$ 0( / 2on3e*tioner !2 - *a#$ an "il$% an 'a# emul$i"n$

Pa$ment

etails

Amount eposited ate

R$. (!! !-.!1.2!1-

Pa$ment /ode

+P ,nline

Place %

//////////////////// +Signature of the ate Applicant-

You might also like