1. A. Raising of Poultry

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

2. B. Origin of Poultry Slaughtered

   	Poultry are raised on the premises.
   	USDA Premises ID number:

   Poultry is purchased from the following farms (include the USDA Premises ID number):

   Name		ID #

   	Poultry is purchased from the following auctions:

3. C. Slaughter

   The USDA Plant Number of this slaughterhouse is:
   The IDOA 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 poultry is performed in the following manner:

   	If the poultry is hand-slaughtered with a sharp knife:
   	If the above box is checked, answer the following:
   		The poultry is alive at the time of slaughter.
   		The poultry is not stunned before slaughter.
   		The knife used during the slaughter is cleaned/sanitized after each use.
   		The poultry is facing Mecca when slaughtered.
   		The poultry is slaughtered by a person who represents him/herself as a Muslim.
   		The slaughterer pronounces an Islamic benediction while performing the slaughter.
   		The poultry 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 the poultry is slaughtered by mechanical means:
   	If the above box is checked, answer the following:
   		The poultry is alive at the time of slaughter.
   		The poultry is not stunned before slaughter.
   		The poultry is facing Mecca when slaughtered.
   		The machine is turned on and supervised by a person who represents him/herself as a Muslim.
   		An Islamic benediction is pronounced when the machine is turned on.
   		The poultry is slaughtered with a swift, deep incision on the neck that cuts the jugular veins and carotid arteries on both sides and also the trachea and esophagus.
   		Poultry that are not adequately slaughtered by the machine are manually slaughtered by a person who represents him/herself as a Muslim slaughterer with Islamic benediction.
   		The poultry is not decapitated.
   		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 as animals that are slaughtered to be sold as halal.

4. D. Post-Slaughter

   1. 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

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

Please check all that apply.