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Statement of Guarantee on the Authenticity of the Information Submitted

Topics to be applied



(): 快 Name: applicant
: ID number : // / / / / ID number: ID / In the case of enterprise application,

please fill /. Guarantee We (personality or the enterprise )guarantee 1抄梀 The application is conducted in accordance with the national law and regulations in involved. 2完抉 All the information submitted in this application is authentic and derived from the reliable source. 3快曲 Bear the responsibility for all the falsehood of the information submitted and will assume all the lawful liability.

忱 Signature of the applicant (or the agent authorized by the applicant) the seal of the enterprise Date: 2007 07 19

1. 完
完 The signature must be done by himself (or herself). In the case of signature made by the agent the written certificate of authorization must be provided. 2.
This format is established by Jiangsu Food and Drug Administration.


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