REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAVITE )
MUNICIPALITY OF ROSARIO ) s.s

Affidavit / Certification of Compliance with FDA Requirements for Renewal of FDA License
with Change of Address

I, _____________, Filipino, of legal age, (single / married / widow), and a resident of

_____________, Philippines, after being duly sworn in accordance with law, depose and state:

That I am the __position__ of __name of company__, a (single proprietorship / domestic

corporation) registered under the laws of the Republic of the Philippines, and which is engaged
in the Food Processing/Manufacturing Business, particularly in the manufacture of
_____________ food products;

That the said company has been granted a License to Operate by the Bureau of Food and Drugs
(FDA) under Licence No. _____________ issued on _____________;

That the company is presently applying for a renewal of its FDA license (or a new FDA Licence
because of its change of business address from _____________ to _____________, Philippines);

That I hereby certify that the company is using the following food chemicals: (enumerate and
describe the food chemicals used);

That I hereby certify that we are getting our supply of the said food chemicals from
_____________ Laboratory and are using the same in the accordance with proportions and
limitations set by the said Laboratory, which are in compliance with the requirements of U.S.
Pharmacoepia (USP) and Food Chemicals Codex (FCC) and are using only food grade ingredients;

That I am executing this Affidavit/Certification to attest to the truth of the foregoing and in
support of our application for a new FDA license and for whatever other legal purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________,

Philippines.

Affiant