Section 190.APPENDIX E Disclosure Statement: Restaurant, Nursing Home, Summer Camp, Caterer or Other Dealer Who Serves Prepared Food

Name of Restaurant, Nursing Home, Summer Camp, Caterer or Other Dealer:

Please check all that apply.

A. General Disclosures

	This establishment sells only food represented as halal as described in this disclosure statement.
	This establishment sells both food represented as halal and food not represented as halal.
	The restaurant, nursing home, summer camp, caterer or other dealer is not under the supervision of a halal certifying entity.
	The restaurant, nursing home, summer camp, caterer or other dealer is under the supervision of the following halal certifying entity.
	Name of Certifying Entity:
	Address:

	All food sold does not contain pork or pork products.
	All food sold does not contain blood as an ingredient.
	All food sold does not contain alcohol.
	All cheese used is certified as halal.
	All milk used is certified as halal.
	This establishment uses separate utensils, cutting boards, cooking utensils, ovens, microwaves and knives for halal and non-halal foods, which are appropriately identified.
	This establishment uses separate refrigerators, freezers and storage areas for food represented as halal and food not represented as halal.
	All food served as halal is not mixed with any non-halal food.
	Alcohol is not used in the preparation of food.

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:

	The name, address and telephone number of the vendors from whom the meat referred to above was purchased:
	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 meat 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 contains 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 poultry 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 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:

	Meat and poultry offered for sale have been slaughtered as halal or zabiha halal and identified as such at the slaughterhouse consistent with Federal labeling guidelines.
	This establishment purchases only meat or poultry labeled halal or zabiha halal from a federally or State inspected meat packing plant.
	Pork or pork products are not sold at this establishment.
	This establishment sells meat or poultry that has not been identified as halal or zabiha halal by the slaughterhouse.

C. Food Packaging

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

	Telephone Number:

D. Cleaners and Sanitizers

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

E. Certification by Establishment

I certify that the above information is correct.


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