Climatarian DishVerification Form Restaurant and Contact Information Contact person (Confidential, used for communication for the verification process) Location Climatarian Dish Two Photographs of the dish We give permission to GoSustainable for using the provided images on social media, website etc to promote the campaign and introduce your Climatarian dish. Yes All ingredients used for the Climatarian dish must comply with the following 5 rules. Plant-based (No use of animal-derived ingredients), Locally sourced where possible (No use of imported ingredients), Unprocessed or minimally processed, Minimally packaged, Organic (At least 80% of total ingredients by weight must be produced without the use of synthetic chemicals, and 100% without genetically modified components) Please list the ingredients in order of weight, beginning with the ingredient that weighs the most and ending with the ingredient that weighs the least. *The supplier's contact is not needed but please provide the information that indicates the ingredient is of local origin, not imported. Ingredients —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic Add More Ingredients Yes More Ingredients —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic —Please choose an option—OrganicNon-organic Are you willing to regularly communicate with our team and provide data such as how many Climatarian dishes sold per month, etc? YesNo Can we disclose the ingredients of your Climatarian dish? (Yes, no problem to disclose./No, it's confidential.) YesNo Please Choose Collaboration with a charity organization that collect surplus food and redistribute to people in need, is a requirement for your Climatarian dish to be verified. Does your restaurant collaborate with such organization? YesNo (I agree with donating Rp.50,000- to a food rescue organization. Choose one organization.) Scholars of Sustenance Indonesia (Bali)FoodCycle Indonesia (Jakarta)Garda Pangan (Surabaya) Declaration I hereby declare that the information provided is true and will inform GoSustainable of any changes. I consent to the conditions.
English 
Indonesian