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    FR-M2OK English Version (v03)

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    Fira Salsabila
    This document contains an application form for a halal certificate for food, beverages, drugs, or cosmetics. It requests information about the applicant company, its products, materials used, and halal supervisors. The form collects details to evaluate if a product and its supply chain meet Islamic halal standards for issuing a halal certificate.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    FR-M2OK English Version (v03)

    Uploaded by

    Fira Salsabila
    20 views6 pages
    This document contains an application form for a halal certificate for food, beverages, drugs, or cosmetics. It requests information about the applicant company, its products, materials used, and halal supervisors. The form collects details to evaluate if a product and its supply chain meet Islamic halal standards for issuing a halal certificate.

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    FR-M2OK English Version (v03) (2)

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    This document contains an application form for a halal certificate for food, beverages, drugs, or cosmetics. It requests information about the applicant company, its products, materials used, and halal supervisors. The form collects details to evaluate if a product and its supply chain meet Islamic halal standards for issuing a halal certificate.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    20 views6 pages

    FR-M2OK English Version (v03)

    Uploaded by

    Fira Salsabila
    This document contains an application form for a halal certificate for food, beverages, drugs, or cosmetics. It requests information about the applicant company, its products, materials used, and halal supervisors. The form collects details to evaluate if a product and its supply chain meet Islamic halal standards for issuing a halal certificate.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 6

    Registration Number : - - - 1

    FR-M2OK
    Registration Date : - -

    Registration Status : New Renewal

    HALAL CERTIFICATE APPLICATION FORM


    FOR FOOD, BEVERAGE, DRUG, OR COSMETIC

    Data of Company
    Company Name :

    Address :

    District/City :
    Province/State : Country :

    Postal Code :

    Phone : E-mail :

    Type of Company : Ltd./Inc. Ltd. Partnership Trading Company Trading Venture

    Cooperative Firm Personal Company Other

    Category of compan: Micro Small Medium Large

    Factory Address :

    (can be in the form of attachment)

    Factory Status : Own Factory Makloon Other

    Applicant,

    (……………………………………)
    Versi 3.0 berlaku mulai tanggal 1 Februari 2020

    Head of Company
    Name :
    Position :

    Phone : E-mail :

    Person in Charge
    Name :
    Position :

    Phone : E-mail :

    Legal Aspect
    No Type of Letter Number of Letter Date of Letter Validity Period Issuing Agency
    Business
    1
    License
    2 Other

    Please attach: copy of business license

    Halal Supervisor
    No. of Certificate of Halal No. & Date of
    No Name ID Card Number Phone
    Supervisor Training Decree

    Please attach: ID Card, copy of halal supervisor certificate, copy of halal supervisor decree, and curriculum vitae (CV).

    Type of Product
    Type of Product*) :
    Trademark :

    Distribution Coverage : Local (Max. 3 Provinces) National (>3 Provinces) International


    Distribution Permit :
    *) see the list of product types
    Please attach copy of distribution permit

    List of Product Names (can be in the form of attachment)


    No. Name of Product Not to be published?
    Matrix of use of Material in Products (can be in the form attachment)
    Name of Product
    No. Name of Material

    List of Material Names (can be in the form of attachment)


    Validity Period
    Name of Type of Halal Certification Number of Halal Supporting
    No Producer Country Supplier of Halal
    Material Material Body/ Agency Certificate Document
    Certificate

    *) raw material/ additional material/ supporting material


    INSTRUCTIONS FOR FILLING HALAL CERTIFICATE APPLICATION FORM
    FOR FOOD, BEVERAGE, DRUG, OR COSMETIC
    Registration Number : to be completed by official
    Registration Date : to be completed by official
    Registration Status : select the option by crossing (x) in the appropriate box (new/ renewal)

    Data of Company
    1 Company Name: complete it with the name of the company applying for halal certification.
    2 Address: complete it with the address of the company.
    3 District/City: complete it with the name of the district/city in acoordance with the address of the company.
    4 Province/State: complete it with the name of the province/state in which the company is located.
    5 Country: complete it with the name of the country in which the company is located.
    6 Postal code: complete it with the postal code/number in which the company is covered.
    7 Phone: complete it with the telephone number of the company.
    8 E-mail: complete it with the e-mail address of the company.
    9 Type of company: complete it by crossing (x) in the box corresponding to the type of business of your company.
    10 Category of company: complete it by crossing (x) in the box corresponding to the business scale/category of your company.
    11 Factory address: complete it with the factory address as the location of production.
    12 Factory status: complete it by crossing (x) in the box that corresponding to your factory status (own factory/ makloon/ other).

    Head of The Company


    1 Name: complete it with the name of the head of the company.
    2 Position: complete it with the position of the head of the company.
    3 Phone: complete it with the phone number of the head of the company.
    4 E-mail: complete it with the e-mail address of the head of the company.

    Person in Charge
    1 Name: complete it with the name of the person appointed by your company to communicate with BPJPH.
    2 Position: complete it with the name of the person in charge's position in your company.
    3 Phone: complete it with the phone number of the person in charge.
    4 E-mail: complete it with the e-mail address of the person in charge.

    Legal Aspect
    1 Type of Letter: complete it with the type of business license.
    2 Number of Letter: complete it with the number of the business license of your company.
    3 Date of Letter: complete it with the date of issuance of the business license of your company.
    4 Validity Period: complete it with the validity period of the business license of your company.
    5 Issuing Agency: complete it with the name of agency/ institution that issued of your company.

    Halal Supervisor
    1 Name: complete it with the name of halal supervisor listed in the decree of your company.
    2 ID Card Number: complete it with the Halal Supervisor's ID Card Number.
    3 Certificate of Halal Supervisor Training: complete it with the number of certificate of Halal Supervisor Training.
    4 Number and Date of Decree: complete it with the number and date of decree of Halal Supervisor in your company.
    5 Phone: complete it with the phone number of Halal Supervisor.

    Type of Product
    Type of Product: complete it with the name of the type of product in accordance with the product submitted for the aplication for halal
    1
    certificate.
    2 Trademark: complete it with the name of the product trademark for which the application for halal certificate is submitted.
    3 Distribution coverage: select the option by crossing (x) in the box corresponding to the distribution area of the product (namely local/ national/
    international) for which the application for halal certificate is submitted.
    4 Distribution permit: complete it with the number of product distribution permit issued by the relevant agency.

    List of Product
    1 Name of Product: complete it with the name of the product for which the halal certification is applied.
    2 Not to be published: mark (✓) in the column not to be published if the product name does not want to be published to the public.

    Matrix of Use of Material in Products (it can be in the form of attachment)


    1 Name of Material: complete it with the name of the material used in production.
    2 Name of Product: complete it with the name of the product submitted for the halal certificate application.

    List of Material Names (it can be in the form of attachment)


    1 Name of Material: complete it with the name of the materials used in the production process.
    2 Type of Material: complete it with the type of material used in the production process (raw material/additional material/supporting material).
    3 Producer: complete it with the name of the producer of the material.
    4 Country: complete it with the name of the country in which producer produces the material.
    5 Supplier: complete it with the name of the supplier company of the material.
    6 Halal Certification Body/ Agency: complete it with the name of the institution which issued the halal certificate of the materials.
    7 Halal Certificate Number: complete it with the halal certification number of the material used.
    8 Validity Period of Halal Certificate: complete it with the validity period of the halal certificate.
    9 Supporting Documents: complete it with the information on other supporting documents stating that the material referred to is halal, if the
    material used is not proven with halal certificate.

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