FOOD SAFETY & STANDARD AUTHORITY OF INDIA Product Approval Application Form 1 ( a ) / ( d ) Date of Application

For FSSAI Office use Only

DETAILS OF FOOD BUSINESS OPERATOR ( FBO )

1.(a) name of the applicant : M/s American Food Corpoartion

1.(b) product name

: NutriGene, Ampro-D ,ProDiet, ( Proprietary Food - Food & Dietary or Health Supplements )

2.(a) contact address : 19A,Ground Floor,Shanmuga Nagar, ( Incl.tel.no.& E.mail ) SIPCOT,Pudukkottai-622002 Tamil Nadu Phone : Mobile: 9944884990 Email : americanfoodcorporation@gmail.com

2.(b) Manufacturing Address

: 19A,Ground Floor,Shanmuga Nagar, SIPCOT,Pudukkottai-622002 Tamil Nadu

3. Previous License Details : Not Applicable ( New Registration & License )

B.

PRODUCT DETAILS

S.No. 1 2 3 4

List of Ingredients Whey Protein Isolate Non-Fat Mlik Solids Malt Extract Powder Soluble Fibre ( Apple )

In %

S.No. 1 2 3 4

List of Additives with INS No. Maltodextrin Cocoa Powder Caramel Powder

In %

C. INDIAN FOOD CODE ( IFC ) DETAILS Name of the product under IFC IFC No. Whey protein Isolate 13.6 Non- Fat Milk Solids 13.6 Malt Extract Powder 13.6 Cocoa Powder 13.6 Maltodextrin 13.6 Soluble Fibre ( Apple ) 13.6 Caramel Powder 13.6 DOCUMENTS TO BE ENCLOSED 1. Product Label / Prototype Label 2. Certificate of Analysis of the product 3. Shelf Life of the Product

Name & Signature of the Applicant