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1、行政許可（行政確認(rèn)）申請(qǐng)材料真實(shí)性保證聲明
Statement of Guarantee on the Authenticity of the Information Submitted
申請(qǐng)事項(xiàng)
Topics to be applied
申請(qǐng)人
applicant
企業(yè)名稱(chēng)(或姓名):
身份證號(hào):
ID number:
ID
Name:
2、
ID number :
（如屬于企業(yè)申請(qǐng)劃“/”。In the case of enterprise application, please fill “/”.）
承諾事項(xiàng)
Guarantee
我（們）保證：
We (personality or the enterprise )guarantee：
1、本申請(qǐng)遵守國(guó)家法律法規(guī)規(guī)章和有關(guān)規(guī)定。
The applicat
3、ion is conducted in accordance with the national law and regulations in involved.
2、所有資料真實(shí)有效，有據(jù)可查。
All the information submitted in this application is authentic and derived from the reliable source.
3、如有虛假，愿意承擔(dān)相應(yīng)的法律責(zé)任。
Bear the responsibility for all the falsehood of the information submitted a
4、nd will assume all the lawful liability.
申請(qǐng)人（或委托代理人）簽名：
Signature of the applicant (or the agent authorized by the applicant)
（企業(yè)蓋章）
（the seal of the enterprise）
日期
Date: 年 月 日
1.申請(qǐng)材料真實(shí)性的保證聲明應(yīng)由申請(qǐng)人（申辦企業(yè)由法定代表人）簽署生效。委托代表人簽署的，應(yīng)出具由申請(qǐng)人簽署的有效委托書(shū)。
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.本表由江蘇省食品藥品監(jiān)督管理局制定。
This format is established by Jiangsu Food and Drug Administration.
行政許可（行政確認(rèn)）申請(qǐng)材料真實(shí)保證聲明
