行政许可 （ 行政确认 ） 申请材料真实性保证声明 Statement of Guarantee on the Authenticity of the Information Submitted 申请事项 Topics to be applied 申请人 applicant 企业名称 (或姓名 ): Name: ID number : （如属于企业申请划 “ /”。 In the case of enterprise application, please fill “ /” .） 承诺事项 Guarantee 我（们）保证： W e(personality or the enterprise )guarantee ： 1、本申请遵守国家法律法规规章和有关规定。 The application is conducted in accordance with the national law and regulations in involved. 2、所有资料真实有效，有据可查。 All the information submitted in this application is authentic and derived from the reliable source. 3、如有虚假，愿意承担相应的法律责任。 Bear the responsibility for all the falsehood of the information submitted and will assume all the lawful liability. 法定代表人（或委托代理人）签名： Signature of the applicant (or the agent authorized by the applicant) （企业盖章） （ the seal of the enterprise ） 日期 Date: 年 月 日 1. 申请材料真实性的保证声明 应由申请人（申办企业由法定代表人）签署生效。委托 代表人签署的，应出具由申请人签署的有效委托书。 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. 本表由江苏省药品监督管理局制定。 This format isestablished by Jiangsu Food and Drug Administration . 身份证号 : ID number: