‫‪Arab Republic of Egypt‬‬ ‫ﺟﻣﻬﻮرﻳﺔ ﻤﺼﺮ اﻠﻌﺮﺑﻴﺔ‬

‫‪National Food Safety Authority‬‬ ‫اﻠﻬﻴﺌﺔ اﻠﻘﻮﻤﻴﺔ ﻠﺴﻼﻤﺔ اﻠﻐﺬاء‬

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‫اﺳﺘﻤﺎرة‪  ‬ﺴﺠ ﻞ‪ ‬ﺑ ﺎﻧﺎت‪ ‬ﻣﺼﻨﻊ‪ ‬أﻏﺬ ﺔ‬

‫‪...............................................‬‬ ‫اﻟﻌﻼﻣﺔ اﻟﺘﺠﺎر ﺔ )إن وﺟﺪ(‪:‬‬ ‫‪...............................................‬‬ ‫اﺳﻢ اﳌﺼﻨﻊ‪:‬‬

‫‪...............................................................................................................................................................‬‬ ‫ﺸﺎط وﻣﻨﺘﺠﺎت اﳌﺼﻨﻊ‪:‬‬

‫‪................................................................................................................................................................. ‬‬ ‫اﻟﻌﻨﻮان اﻟﺘﻔﺼﻴ ‪:‬‬
‫‪............................................... ‬‬ ‫ا ﺎﻓﻈﺔ‪:‬‬ ‫‪............................................... ‬‬ ‫اﻟ ‪ /‬اﳌﺪﻳﻨﺔ‪:‬‬
‫‪............................................... ‬‬ ‫رﻗﻢ ﻓﺎﻛﺲ‪:‬‬ ‫‪............................................... ‬‬ ‫رﻗﻢ ﺗﻠﻴﻔﻮن‪:‬‬
‫‪............................................... ‬‬ ‫‪...............................................‬‬
‫ﻣﻮﻗﻊ اﳌﺼﻨﻊ ﻋ اﻷﻧ ﻧﺖ‪:‬‬ ‫اﻟ ﻳﺪ اﻻﻟﻜ و ﻲ ﻟﻠﺘﻮاﺻﻞ‪:‬‬

‫‪............................................... ‬‬ ‫ﺑﻴﺎﻧﺎت اﻟﺘﻮاﺻﻞ ﻣﻊ اﳌﺎﻟﻚ‬ ‫‪............................................... ‬‬ ‫اﺳﻢ اﳌﺎﻟﻚ‪:‬‬

‫‪............................................... ‬‬ ‫ﺗﻠﻴﻔﻮن اﳌﺪﻳﺮاﳌﺴﺌﻮل‪:‬‬ ‫‪............................................... ‬‬ ‫أﺳﻢ اﳌﺪﻳﺮاﳌﺴﺌﻮل‪:‬‬
‫‪............................................... ‬‬ ‫ﻞ اﻟﺘﺠﺎري‪:‬‬ ‫ﺗﺎر ﺦ اﻟ‬ ‫‪............................................... ‬‬ ‫ﻞ اﻟﺘﺠﺎري‪:‬‬ ‫رﻗﻢ اﻟ‬
‫ﻞ اﻟﺼﻨﺎ ‪...............................................  :‬‬ ‫ﺗﺎر ﺦ اﻧ ﺎء اﻟ‬ ‫‪............................................... ‬‬ ‫ﻞ اﻟﺼﻨﺎ ‪:‬‬ ‫رﻗﻢ اﻟ‬
‫‪ ‬‬ ‫‪............................................... ‬‬ ‫رﻗﻢ اﻟﺒﻄﺎﻗﺔ اﻟﻀﺮ ﻴﺔ‪:‬‬

‫‪...............................................................................................................................................................‬‬ ‫ﻧﻈﻢ ا ﻮدة اﳌﻄﺒﻘﺔ‪:‬‬

‫ﻋﺪد اﻟﻌﻤﺎﻟﺔ اﳌﺆﻗﺘﺔ ﺑﺎﳌﺼﻨﻊ ‪............................................... ‬‬ ‫‪............................................... ‬‬ ‫ﻋﺪد اﻟﻌﻤﺎﻟﺔ اﻟﺜﺎﺑﺘﺔ ﺑﺎﳌﺼﻨﻊ‬
‫‪............................................... ‬‬ ‫ﻋﺪد اﻟﻮردﻳﺎت‪:‬‬ ‫‪............................................... ‬‬ ‫ﻣﻮاﻋﻴﺪ اﻟﻌﻤﻞ ﺑﺎﳌﺼﻨﻊ‪:‬‬
‫‪............................................... ‬‬ ‫أﻳﺎم اﻹﺟﺎزة اﻷﺳﺒﻮﻋﻴﺔ‪:‬‬ ‫‪............................................... ‬‬ ‫ﻋﺪد ﺧﻄﻮط اﻻﻧﺘﺎج‬
‫‪............................................... ‬‬ ‫ﻣﺼﺪراﳌﻮاد ا ﺎم )ﺳﻮق‬ ‫‪............................................... ‬‬ ‫اﻟﺪول اﻟ ﻳﺼﺪرﻟ ﺎ اﳌﺼﻨﻊ‬
‫ﻣﺤ ‪/‬اﺳﺘ اد‪/‬ﻛﻼ ﻤﺎ(‬
‫‪...............................................................................................................................................................‬‬ ‫أﺳﻤﺎء وﻋﻨﺎو ﻦ ﻣ ﺸﺂت‬
‫اﻷﻏﺬﻳﺔ اﻟﺘﺎ ﻌﺔ ﻟﻠﻤﺼﻨﻊ‬
‫‪............................................................................................................................................................... ‬‬
‫)ﻣﺨﺎزن‪ -‬ﻓﺮوع ﺑﻴﻊ‪ -‬أﺧﺮى(‬
‫ً‬
‫ﺗﻮﻗﻴﻊ ﻣﻤﺜﻞ اﳌ ﺸﺄة‬ ‫ﺧﺎﺗﻢ اﳌ ﺸﺄة‬ ‫‪/‬‬ ‫‪/‬‬ ‫ﺗﺤﺮ ﺮا ‪:‬‬

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‫ﻓﺎﻛﺱ‪٠٢/٢٧٩٣٣٤٩٦ :‬‬ ‫ﺗﻠﻳﻔﻭﻥ‪٠٢/٢٧٩٣٣٤٩٣ :‬‬ ‫‪ ١١٠‬ﺷﺎﺭﻉ ﺍﻟﻘﺻﺭ ﺍﻟﻌﻳﻧﻲ‪ ،‬ﺍﻟﻘﺎﻫﺭﺓ‬

‫ﺑﺭﻳﺩ ﺇﻟﻛﺗﺭﻭﻧﻲ ﺧﺎﺹ ﺑﺗﺳﺟﻳﻝ ﺍﻟﻣﺻﺎﻧﻊ‪food.factory@nfsa.gov.eg :‬‬ ‫ﻣﻭﻗﻊ ﺍﻟﻬﻳﺋﺔ ﻋﻠﻰ ﺷﺑﻛﺔ ﺍﻹﻧﺗﺭﻧﺕ‪  www.nfsa.gov.eg :‬‬
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