DATA PELAKU USAHA

PENGAJUAN SERTIFIKAT HALAL MELALUI SELF DECLARE

A. Nama Pelaku Usaha (sesuai KTP) : _____________________________________________

B. Nomor NIK : _____________________________________________
C. Tempat Tanggal Lahir : ____________________/_____/____________/ ______
D. Alamat
1. Dusun : _____________________________________________
2. Desa / Kelurahan : _____________________________________________
3. Kecamatan : _____________________________________________
E. Nomor Hand Phone : _____________________________________________
F. Email dan Password : _____________________________________________
G. Nomor Induk Berusaha / NIB : _____________________________________________
H. Mulai Usaha Sejak : ….. / ……
I. Data Produk
1. Nama / Jenis Produk I : _____________________________________________
_____________________________________________
_____________________________________________
2. Merk (jika ada) : _____________________________________________
3. Daftar bahan yang digunakan beserta merk

1 9
2 10
3 11
4 12
5 13
6 14
7 15
8 16

4. Cara Pembuatan (singkat) untuk produk ……………………………

1) ________________________________________________________________________
__________________________________________________________________________
2) ________________________________________________________________________
__________________________________________________________________________
3) ________________________________________________________________________
__________________________________________________________________________
4) ________________________________________________________________________
__________________________________________________________________________
5) ________________________________________________________________________
__________________________________________________________________________
6) ________________________________________________________________________
__________________________________________________________________________
 5. Cara Pembuatan (singkat) untuk produk ……………………………
1) ________________________________________________________________________
__________________________________________________________________________
2) ________________________________________________________________________
__________________________________________________________________________
3) ________________________________________________________________________
__________________________________________________________________________
4) ________________________________________________________________________
__________________________________________________________________________
5) ________________________________________________________________________
__________________________________________________________________________
6) ________________________________________________________________________
__________________________________________________________________________
6. Cara Pembuatan (singkat) untuk produk ……………………………
1) ________________________________________________________________________
__________________________________________________________________________
2) ________________________________________________________________________
__________________________________________________________________________
3) ________________________________________________________________________
__________________________________________________________________________
4) ________________________________________________________________________
__________________________________________________________________________
5) ________________________________________________________________________
__________________________________________________________________________
6) ________________________________________________________________________
__________________________________________________________________________

Contoh
KERIPIK SINGKONG Sedap
A. Bahan-bahan
1. Singkong
2. Garam cap Kapal
3. Bawang putih
4. Air
5. Minyak goreng “Minyakita”
6. Plastik

B. Cara Pembuatan
1. Kupas singkong
2. Iris tipis-tipis lalui dicuci sampai bersih dg air mengalir dan tiriskan
3. Untuk bumbu, haluskan garam dan bawang putih dan tambahkan air secukupnya
4. Masukkan / celupkan singkong ke dalam bumbu yang sudah disiapkan lalu tiriskan
5. Masukkan ke dalam penggorengan sampai matang
6. Angkat, tiriskan, lalu dikemas dengan plastik

C. Foto Produk

Dokumen tamabahan * Foto KTP

** Foto Produk