1. A. General Disclosure

   	This establishment sells only halal foods.
   	This establishment sells both halal and non-halal foods.
   	This establishment sells only meat and poultry as halal.
   	This establishment sells dairy goods as halal.
   	This establishment sells bakery products as halal.
   	This establishment makes no representation as to the halal status of its foods other than that which appears on the package label of prepackaged food.
   	Meat sold at this establishment is under the supervision of the following halal certifying entity:
   	Name:
   	Address:
   	Telephone Number:

   	Poultry sold at this establishment is under the supervision of the following halal certifying entity:
   	Name:
   	Address:
   	Telephone Number:

   	Dairy products sold at this establishment are under the supervision of the following halal certifying entity:
   	Name:
   	Address:
   	Telephone Number:

   	Bakery goods sold at this establishment are under the supervision of the following halal certifying entity:
   	Name:
   	Address:
   	Telephone Number:

   	This establishment uses separate utensils, cutting boards, machine slicers, meat grinders, knives and other equipment for halal and non-halal foods and the equipment is appropriately identified.
   	This establishment uses separate refrigerators, freezers and storage areas for halal and non-halal food.
   	Non-halal food products are not mixed with halal food products.

2. B. Meat and Poultry

   Meat offered for sale at this establishment has been purchased from the vendors listed below who made the following representations. Each vendor must have Part B (Meat) filled out individually:

   Name:
   Address:
   Telephone Number:
   IDOA halal registration number (if applicable):

   	The animal was fed only 100% vegetarian feed, organic feed or Amish feed, none of which contains any animal by-products.
   	The animal was raised without added hormones.
   	The animal was alive at the time of slaughter.
   	The animal was not stunned before slaughter.
   	The animal was hand-slaughtered with a sharp knife.
   	The knife used during the slaughter was cleaned/sanitized after each animal.
   	The animal was facing Mecca when slaughtered.
   	The animal was slaughtered by a person who represents him/herself as a Muslim.
   	The slaughterer pronounced an Islamic benediction while performing the slaughter.
   	The animal was 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 was not severed at the time of slaughter.
   	Only non-animal derived/non-alcohol based cleansers and sanitizers were used to wash/clean the equipment.
   	The animal was drained of blood following the slaughter.
   	The animal slaughtered to be sold as halal was stored in a cooler or freezer that contains only meat or poultry to be sold as halal.
   	If any additional steps or procedures were performed, they were:

   The poultry offered for sale at this establishment has been purchased from the vendors listed below who made the following representations. Each vendor must have Part B (Poultry) filled out individually:

   	The name, address and telephone number of the vendors from whom the poultry referred to above was purchased:
   	Name:
   	Address:
   	Telephone Number:
   	IDOA halal registration number (if applicable):

   	The poultry was fed only 100% vegetarian feed, organic feed or Amish feed, none of which contain any animal by-products.
   	The poultry was raised without added hormones.
   	The poultry was alive at the time of slaughter.
   	The poultry was not stunned before slaughter.
   	The poultry was slaughtered by mechanical means.
   	The poultry was hand-slaughtered with a sharp knife.
   	The knife used during the slaughter was cleaned/sanitized after each use.
   	The poultry was facing Mecca when slaughtered.
   	The poultry was slaughtered by a person who represents him/herself as a Muslim.
   	The slaughterer pronounced an Islamic benediction while performing the slaughter.
   	The animal was slaughtered with a swift, deep incision on the neck that cut the jugular veins and carotid arteries on both sides and also the trachea and esophagus.
   	The spinal cord was not severed at the time of slaughter.
   	Only non-animal derived/non-alcohol based cleansers and sanitizers were used to wash/clean the equipment.
   	The poultry was drained of blood following the slaughter.
   	The poultry slaughtered to be sold as halal was stored in a cooler or freezer that contains only meat or poultry to be sold as halal.
   	If any additional steps or procedures were performed, they were:

   	This establishment purchases only meat or poultry labeled halal or zabiha halal from a federally inspected meat packaging plant.
   	This establishment sells meat or poultry that has not been identified as halal or zabiha halal by the slaughterhouse.
   	Pork or pork products are not sold at this establishment.

3. C. Bakery Products

   	Bakery products sold here do not contain any alcohol.
   	Bakery products sold here do not contain any pork, animal fat or lard.
   	Bakery products sold here do not contain any non-halal beef gelatin.
   	Bakery products sold here contain only gelatin derived from plants.
   	Bakery products sold here contain only gum derived from plants.

4. D. Milk and Dairy Products

   	All cheese sold here is certified as halal.
   	The name, address and telephone number of the halal certifying entity is:
   	Name:
   	Address:
   	Telephone Number:

   	All milk sold here is certified as halal.
   	The name, address and telephone number of the halal certifying entity is:
   	Name:
   	Address:
   	Telephone Number:

5. E. Food Products Prepared On Site

   	Prepared food labeled or represented as halal does not contain or use any ingredients from an animal not represented as halal by the slaughterhouse.
   	Prepared food labeled or represented as halal does not contain any product containing pork.
   	Prepared food labeled or represented as halal does not contain any alcohol.
   	No alcohol is used in the preparation of any prepared food represented as halal.

6. F. Food Packaging

   Food packaging materials have been certified as halal by the following halal certifying entity:

   Name:
   Address:
   Telephone Number:

7. G. Cleaners and Sanitizers

   Only non-animal derived/non-alcohol based cleansers and sanitizers are used to wash/clean the equipment.

8. H. Certification by Retailer

   I certify that the above information is correct.

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

For purposes of this disclosure, non-halal means food that this establishment does not represent to be halal.

Please check all that apply.