Statement of Ingredients and Additives

(To be printed on letter Head of Company/Firm)

1. Name of the Proprietary Food:

2. Nearest Food category no.:
3. Nearest Food category name:

Ingredients:
Ingredients FSSR Std. No./Permitted to use in FSSR
S.No. (Name of the ingredients) No.

Additives:

S.No. Name of the Additives INS NO. Maximum Limit/G.M.P

Signature of FBO/Authorized Signatory with seal