Declaration by Exporting FBO

Involving in Export of NON-STANDARDIZED PRODUCTS

( including Proprietary Food and Other Health Supplement / Nutraceuticals)

Name of the Product

Name of the Importing Country

Whether Product IF YES , Choose/ Mention the Food Category from the following
falls under the
1. Proprietary Food
Food Category of
2. a. Health Supplement
Indian Regulation b. Nutraceuticals,
c. Food for Special Medical Purpose
d. Food for Special Dietary Purpose
e. Specialty foods containing botanical ingredients
f. Pre-Biotic Food / Pro-biotic Food.
IF No, Mention the Food Category as per the
Regulation of the Importing Country

Name Of the Complying as per If NOT Permissible Enclose the Copy of

Ingredient and in the Indian FSSR, the Specification of
Indian FSS Regulation
Additive Mention the the Importing
Regulation Country
Number of the
( If yes , Mention ( Yes/ No)
Importing
Country
the Regulation
Number in FSSR)

A B C D

Contd….
Declaration :

I /We hereby declare that the Information including the copy of the Specification of the importing
country as given above is authentic and truthful. The applied product is Food only and it is in
compliance with the Regulations of the Importing Country and this product will not sold in the Domestic
Market in any form.

Name and Signature of the Authorized Signatory

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For office use ( Remark based on the above Input by EFBO and Tick any one)

1 Ingredients and Additives are as per FSSR , To be included in Domestic KoB also

2 Ingredients and Additives are NOT as per FSSR , Foreign Country Specification
enclosed and Declaration given by EFBO, To be included in ONLY EXPORT KOB