gjpTr; rhd;W tpz;zg;gk; m/ FORM – A REGISTRATION

1. tpz;zg;gjhhpd; ngaH

tpz;zg;gjhhpd; jd;ik
(chpikahsH / ,jutif)
2. Designation (Proprietor /
Others)

tzpfj;jpd; tif
3. kind of business

czT tzpfk; cs;s fl;blj;jpd; Kfthp

4. address of food business

premise

5. efuhl;rp my;yJ xd;wpag; gFjp

6. njhlHGf;fhd Kfthp

7. miyNgrp vz;

8. Email Id

czT nghUl;fspd; tpguk;

9. Name of the food category

10. vj;jid tUlk; tpz;zg;gpf;fpwPHfs;

11. nrYj;jg;gl;l tpz;zg;gj; njhif

 Declaration

I, Mr./Ms./Mrs. ------------------------------------- S/o / D/o Mr. ------------------------------------,

R/o ----------------------------------------------------------------------- do here by solemnly affirms

and declares that all information and particulars furnished here by me are true and correct

to the best of my knowledge. I further declare that the food business conducted or proposed

to be conducted by/through me conforms/shall conform to the Food Safety and Standards

Act, Regulation/ Bye-laws enacted thereunder, and specifically to the Guidelines on Hygiene

and Sanitary Practices provided under Schedule 4 of the Registration and Licensing

Regulation published by the Food Safety and Standards Authority of India or any person

authorized on its behalf from time to time.

Dated: (Signature)