Specimen declaration confirming the premises address, ownership or occupancy status and intended food business activities for FSSAI Registration or Licence purposes.

Illustrative format

SPECIMEN

DECLARATION RELATING TO THE PREMISES USED FOR FOOD BUSINESS

I/We, ______________________________, in the capacity of ______________________________ of ______________________________, hereby declare that the food business is/will be carried on at the premises situated at: ____(Full address)__________.

I/We further declare that the above premises are occupied/used by the food business under the following basis:  ☐ Owned   ☐ Leased/Rented   ☐ Licensed   ☐ Other: ____________.

The premises are intended to be used for the following food business activity/activities:
1. ______________________
2. ______________________
3. ______________________

I/We confirm that the information provided above is true to the best of my/our knowledge and that any material change in the business premises or relevant particulars will be dealt with through the applicable regulatory process.

Declaration

I/We understand that this declaration is an illustrative supporting document and does not replace any specific premises proof or document prescribed by the applicable FSSAI/FoSCoS requirement.

Name: ______________________________
Designation/Capacity: ______________________________
Signature: ______________________________
Mobile/Email: ______________________________
Date: ______________________________
Place: ______________________________

Date: ____________   

Place: ____________