INCOMETAX DEPARTMENT GOVT.

OF INDIA

Permanent Account Number Card

EISPR4797F
TT Name
REKHA
fum 57TTRI Father's Name
BIRAJ PAL TYAGI
03082019
artra
Dale of Birth
01/01/1972 BETRSignature

Government of India
Rekha
Tfafa/dOB: 01/01/1972
fs/ FEMALE

8117 6383 5810

VID 9166 B824 1861 0591
 Declaration for applicant for new Registration Certificate
I declare that

a) I ensure that articles of food mentioned in form satisfy the requirements of FSS
Act 2006,
Rules and Regulations made thereunder.
b) I shall comply with the general hygiene and sanitary requirements as
mentioned in the
Schedule 4 of the FSS (Licensing and Registration of Food
2011.
Businesses) Regulations,
c) Expected Annual turnover of the food business is under Rs.12 Lacs. I will apply for
License as and when annual turnover of food businesses exceeds Rs. 12 Lacs.

I do hereby solemnly affirm and declare that all information and particulars furnished here by me
are true and correct to the best of my knowledge.

Date:(o27-o3| 202
Place:

Signature
Name of the applicant

Rerla