Sample Form

(See rule 11)

To

(Name and address of the vendor)
…………………………………
…………………………………
…………………………………
…………………………………

The stock of article of food detailed below has this day been seized by me under the provisions of sub-section (4) of section 10 of the Prevention of Food Adulteration Act, 1954 (37 of 1954), from the premises of ………………………………….. situated at ……………………………………..

Details of article of food seized.

Dated ………………									

Food Inspector
Area…………………