Halal Products Application Form International 2009

Halal Hub Division The Department Of Islamic Development Malaysia

HALAL APPLICATION FORM FOR PRODUCTS

www.halal.gov.my

PRODUCTS/CONSUMER GOODS Part A: Company Information Company Registration No. : Type Of Application Name of Company:

Address of Company:

( ) New ( ) Renew ( ) Additional Product

Type of Business: Manufacturing Subcontract

Postcode: District: State: Tel. No: Fax No: Website: http::// Company e-mail:

Type of Product Food Product Consumer Product

No of Shift: Working Hours: From:

to:

Contact Person No. 1. 2. 3. 4. 5.

Name

Designation

Telephone

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Part B: Factory Information Name of Factory:

Type of Business: Manufacturing Subcontract

Address of Factory: No of Shift: Working Hours: From:

to:

Postcode: District: State: Tel No: Fax No: Website: http::// Company e-mail:

Contact Person No. Name 1. 2. 3.

Designation

Telephone

Particular of Personnel Assigned For Halal Matters No Name 1. 2. 3.

Designation

Telephone

IC No.

Working Hours

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Part C: Additional Information i. Quality Assurance and Control Procedures (If any) Mark [X] the hygiene and quality programs/procedures adopted in the premise Type Of Quality Assurance HACCP ISO GMP TQM Scheduled Hygiene and Sanitation Program (Please Specify) Ordinary Cleaning

Factory [ ] [ ] [ ] [ ] [ ] [ ]

Please declare whether your factory is handling/manufacturing/processing/storing any of these materials or ingredients in your premises: ii.

Swine/Lard: Animal Source (Specify): Liquor: Poison: Chemicals:

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Part D: Products i. No

Name and Brand Name of the Product to Be Certified Name Of Products

Brand

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ii.

List All Ingredients for each product to be certified (this page can be duplicated according to the number of product) Name Of Product Ingredient Source Plant Animal Chemical Natural Other Plant Animal Chemical Natural Other Plant Animal Chemical Natural Other Plant Animal Chemical Natural Other Plant Animal Chemical Natural Other Plant Animal Chemical Natural Other Plant Animal Chemical Natural Other

Name & Full Address Of Manufacturer Halal Status

-

Yes Specify No

-

Yes Specify No

-

Yes Specify No

-

Yes Specify No

-

Yes Specify No

-

Yes Specify No

-

Yes Specify No

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iii.

State the Type of Packaging Material Used [ [ [ [ [ [

] Box ] Bottle ] Paper ] Plastic ] Aluminium Foil ] Others (Please Specify)

Part E: Applicant’s Declaration I declare that all particulars stated above and the attachments are true to the best of my knowledge.

…………………………………… (CEO/ Owner/Company’s Representative)

……………………………… (Date of Application)

Name: Designation: Tel. No: Fax No: Email:

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