Form IL406-1691 "Registration of Dealers of Halal Food Products" - Illinois

What Is Form IL406-1691?

This is a legal form that was released by the Illinois Department of Agriculture - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2007;
  • The latest edition provided by the Illinois Department of Agriculture;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form IL406-1691 by clicking the link below or browse more documents and templates provided by the Illinois Department of Agriculture.

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Download Form IL406-1691 "Registration of Dealers of Halal Food Products" - Illinois

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This form can be filled in, saved, printed and mailed to:
Illinois State Fairgrounds
Office Use Only
P.O. Box 19281
New
Renewal
Springfield, IL 62794-9281
Reg. #:
Illinois State Fairgrounds
Fee Rec’d:
P.O. Box 19281
By:
Springfield, IL 62794-9281
Issue date:
217-785-4709 (Voice/TTY)
Registration of Dealers of Halal Food Products
(Each location requires a separate registration)
Business Information:
Business name: _____________________________________________________________________________________
Business address: ________________________________________________ City: ______________________________
State: _________ Zip Code: _________________Business phone: (____)__________________
Certifying entity information:
Name of certifying entity: ____________________________________________________________________________
Address: __________________________________________________City: ____________________________________
State: _________ Zip Code: _________________Business phone: (____)__________________
Fee:
Please submit the $75.00 registration fee with the registration form. Do not send cash. Make check or money order
payable to “Illinois Department of Agriculture”.
Disclosure Statement:
All registrations require a disclosure statement, registrations without disclosure statements will be returned. The following
disclosure statement(s) are enclosed with this registration.
( )
Slaughterhouse − Cattle, goats, sheep, and lambs (Appendix A)
( )
Slaughterhouse − Poultry (Appendix B)
( )
Distributor (Appendix C)
( )
Retail establishment (Appendix D)
( )
All other establishments that advertise, represent, or hold themselves out as selling, preparing, or maintaining
food as halal, including, but not limited to, manufacturers, wholesalers, restaurants, hotels, catering facilities,
summer camps, bakeries, delicatessens, licensed health care facilities, freezer dealers, and food plan companies
(Appendix E).
I certify that all food labeled halal is kept in the halal way and is from halal sources.
Signature: _________________________________________________________________________________________
Print Name: _______________________________________________________________________________________
Title: _____________________________________________________________________________________________
Date: _____________________________________________________________________________________________
Important notice: The state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 815 ILCS 505/2LL. Failure to provide this
information shall prevent this form from being processed. This form has been approved by the State Forms Management Center.
IL406-1691 (12-07)
This form can be filled in, saved, printed and mailed to:
Illinois State Fairgrounds
Office Use Only
P.O. Box 19281
New
Renewal
Springfield, IL 62794-9281
Reg. #:
Illinois State Fairgrounds
Fee Rec’d:
P.O. Box 19281
By:
Springfield, IL 62794-9281
Issue date:
217-785-4709 (Voice/TTY)
Registration of Dealers of Halal Food Products
(Each location requires a separate registration)
Business Information:
Business name: _____________________________________________________________________________________
Business address: ________________________________________________ City: ______________________________
State: _________ Zip Code: _________________Business phone: (____)__________________
Certifying entity information:
Name of certifying entity: ____________________________________________________________________________
Address: __________________________________________________City: ____________________________________
State: _________ Zip Code: _________________Business phone: (____)__________________
Fee:
Please submit the $75.00 registration fee with the registration form. Do not send cash. Make check or money order
payable to “Illinois Department of Agriculture”.
Disclosure Statement:
All registrations require a disclosure statement, registrations without disclosure statements will be returned. The following
disclosure statement(s) are enclosed with this registration.
( )
Slaughterhouse − Cattle, goats, sheep, and lambs (Appendix A)
( )
Slaughterhouse − Poultry (Appendix B)
( )
Distributor (Appendix C)
( )
Retail establishment (Appendix D)
( )
All other establishments that advertise, represent, or hold themselves out as selling, preparing, or maintaining
food as halal, including, but not limited to, manufacturers, wholesalers, restaurants, hotels, catering facilities,
summer camps, bakeries, delicatessens, licensed health care facilities, freezer dealers, and food plan companies
(Appendix E).
I certify that all food labeled halal is kept in the halal way and is from halal sources.
Signature: _________________________________________________________________________________________
Print Name: _______________________________________________________________________________________
Title: _____________________________________________________________________________________________
Date: _____________________________________________________________________________________________
Important notice: The state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 815 ILCS 505/2LL. Failure to provide this
information shall prevent this form from being processed. This form has been approved by the State Forms Management Center.
IL406-1691 (12-07)
APPENDIX A Disclosure Statement: Slaughterhouse − Cattle, Goats, Sheep and Lambs
Name of Slaughterhouse:
Please check all that apply.
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.
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:
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:
Appendix A 1
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.
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.
Appendix A 2
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.
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
IL406-1696 (12-07)
Appendix A 3
APPENDIX B Disclosure Statement: Slaughterhouse − Poultry
Name of Poultry Slaughterhouse:
Please check all that apply.
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.
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:
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:
Appendix B 1