1. A. Raising of Animals

   	This establishment slaughters only cattle, goats, sheep and lambs that have only been fed feed that does not contain animal by-products, such as 100% vegetarian feed, organic feed or Amish feed.
   	The cattle, goats, sheep and lambs are free from diseases and raised without added hormones.
   	The cattle, goats, sheep and lambs slaughtered here do not have any sub-therapeutic antibiotics in their system at the time of slaughter.

2. B. Origin of Animals Slaughtered

   	Animals are raised on the premises.
   USDA premises ID number:

   Animals are purchased from the following farms (include the USDA Premise ID Number):

   Name		ID #

   	Animals are purchased from the following auctions:

3. C. Slaughter

   The USDA Plant Number of this slaughterhouse is:
   The Illinois Department of Agriculture plant number of this slaughterhouse is:

   	The slaughterhouse is not under the supervision of any halal certifying entity.
   	The slaughterhouse is under the supervision of the following halal certifying entity.
   	Name of Certifying Entity:
   	Address:

   The slaughter of animals is performed in the following manner:

   	The animal is alive at the time of slaughter.
   	The animal is not stunned before slaughter.
   	The animal is slaughtered with a sharp knife.
   	The knife used during the slaughter is cleaned/sanitized after each animal.
   	The animal is facing Mecca when slaughtered.
   	The animal is slaughtered by a person who represents him/herself as a Muslim.
   	Name:
   	Certifying entity:
   	The slaughterer pronounces an Islamic benediction while performing the slaughter.
   	The animal is slaughtered with a swift, deep, transverse incision on the neck that causes a simultaneous and instantaneous severance of the jugular veins and carotid arteries on both sides, including the trachea and esophagus.
   	The spinal cord is not severed at the time of slaughter.
   	If any additional steps or procedures are performed, they are:
   	Pigs are slaughtered in this slaughterhouse.

   	If the above box is checked, answer the following:
   		Pigs are slaughtered on separate equipment.
   		Pigs are slaughtered on the same day as animals that are slaughtered to be sold as halal.
   		Pigs are slaughtered on a different day than animals that are slaughtered to be sold as halal.

4. D. Post-Slaughter

   	No part of the animal is cut before the animal is completely dead.
   	Only non-animal derived/non-alcohol based cleansers and sanitizers are used to wash/clean the equipment.
   	The animal is drained of blood following the slaughter.
   	The animal slaughtered to be sold as halal is stored in a cooler or freezer that contains only meat or poultry to be sold as halal.
   	Animals are labeled as halal or zabiha halal consistent with the Food Standards and Labeling Policy Book of the USDA.
   	If the slaughterhouse fabricates meat to be sold as halal, food packaging materials have been certified as halal by a halal certifying entity.
   	If the slaughterhouse fabricates meat to be sold as halal, the meat has not been co-mingled with any food or food product not represented to be halal.

5. E. Certification by Slaughterhouse

   I certify that the above information is correct.

   	Signature
   	Printed Name
   	Business Name
   	Address
   	City		State		Zip Code
   	Telephone Number		Date

Please check all that apply.