Sample Form

(See rule 17)

Memorandum to Public Analyst
From
……………………………
………………………………

To

The Public Analyst,
…………………………
…………………………
No. ……………………….. dated the ………………………. 20………………

Memorandum

The sample described below is sent herewith for analysis under clause (b) of sub-section (1) of section 10 and/or clause (c)(ii) of sub-section (1) of section 11 of the Prevention of Food Adulteration Act, 1954:

(1) Code number and Serial number of Local (Health) Authority.
(2) Name of the Vendor.
(3) Date and place of collection.
(4) Nature of article submitted for analysis.
(5) Nature and quantity of preservative, if any, added to the sample.

2. A copy of this memo, and specimen impression of the seal used to seal the packet of sample is being sent separately by post/hand. 

Food Inspector,
Area ………….