00123-23

County Government Of

town Sub County

P.O Box 469-40300
Email: finance@homabay.go.ke

Tulipe Ushuru Tujenge #Endless Potential

FOOD, DRUGS AND CHEMICAL SUBSTANCES ACT (Cap 254)

Certificate Of Medical Examination

Form D

I hereby certify that I have on this day examined Mr jane doe and that in my opinion he/she is fit under the food, drug and chemical substances (Food Hygiene) Regulations to work at Shivling Supermarket Plot NO. 203/123/1234. Physical Address Athi river.

This certificate is valid for 6 Months with effect from 12 Jan 2024.

Valid From
12 Jan 2024 		Expiry Date
31 Dec 2024 		Invoiced By
 Kelvin Otati Umtata

12 Jan 2024

Date Approved

The signature

John Doe, Director Public Health

Permit No.: 00123-23 Date Downloaded 23 Oct 2023 12:34 AM

County Government of

Notice: Any alterations done after insoection that downngread compliance will render the premises/Vehicle non-compliant and shall hold the owner of the building/premises liable for prosecution.