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(Affidavit of Compliance with BFAD Requirements on the Use of Certain

Food Chemicals)

REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.

City/Municipality of _____________)

x-----------------------x

AFFIDAVIT / CERTIFICATION

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 (BFAD) under Licence No.
_____________ issued on _____________;

That the company is presently applying for a renewal of its BFAD license
(or a new BFAD 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 BFAD license
and for whatever other legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this


_____________ at _____________, Philippines.

AFFIANT

(JURAT)

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