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/4 , 2014

, /

RAVI DWIVEDI

8871861199,8827460280

Office Address (Authorized licensee)

Cyberedge Infoserve

23/348,Nr. Hanuman mandir Amahia !e"a 48#$$%

&ontact'#3$%8%%%,*8*44*888,$*##2422%$

Form "A"

[See Regulation 2.1.1 and Regulation 2.1.7]

Application for Registration under Food Safety andStandards Act, 2006

Application No: 20140100300024606

Name of Applicant / Company : jahnvi kirana store

Kind of Business :Retailer

kirana

Designation : Individual

Address of Premiseswhere food business islocated

Address :indane gas godown ke samne

gram maidani distt rewa

State : Madha !radesh

District : Rewa

Correspondence Addressetails

Address :indane gas godown ke samne

gram maidani distt rewa

State : Madha !radesh

District : Rewa

Sub- : "u#ur

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Sub-

Division: "u#ur

Village : Maidani

in

Code: 4$6001

Division

Village : %/&

in

Code: 4$6001

Contact etails

!el No : %&"obile

No: '($46003)(

#a$ No : %& %mail : *+eredge-gmail.*om

Contact

erson: +rijendra mani singh

!ther etails

&n case of Ne' business ( intended date of start : 04/01/2014

"n case of Sessional business# State theopening and closing period of the

$ear %

January-December

Source of &ater Suppl$ % Public

Sanction 'lectricit$ (oad or )P *sed % NA

*pload Photo % RGPHID321737.jpeg

*pload ocument for "dentit$ Proof

+eg% Ration Card# ,oter " Card etc.-

PAN Car

RGID321737.jpeg

escription of the food items proposed to bemanufactured or sold%

Sl.

o.ame of the food categor$

1!1 - Dairy pr"uc#$ an anal"gue$% e&cluing pr"uc#$ "' '""

ca#eg"ry !2.!

2 16 !reared oods

3 1( - Reay-#"-ea# $a)"urie$

4 0( one*tioner

( !2 - *a#$ an "il$% an 'a# emul$i"n$

Pa$ment etails

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Amount R$. (!!Pa$ment

/ode+P ,nline

eposited ate !!12!1

Place

%

ate

%

////////////////////

+Signature of the

Applicant-