#1 US Halal Certification Agency

Company Name

First Name

Last Name

Email Address

Contact Number

Street Address

City

State

Zip Code

Country

Facility Type (select most appropriate)

Product Type (select all that apply)

Approximate Square Footage

Number Of Products Sold As Halal Or To Be Certified

Number of Total Unique Ingredients:

Urgency? (Delivery Expectation)

Standard Processing

Expedited Processing (Delivery within 10 days)

Brand/Logo/Package Design Needed?

Product for Export? Select all countries that apply

Dual Language (Arabic) Assistance Needed?

Yes

No

Special Instructions

Needs Assessment Questionnaire