We know you have other options.Thank you for choosing The Paleo Foundation again. Paleo Certification Renewal Application Legal Business Entity* (Legal Business Entity) seeks permission to use the “Certified Paleo” Trademark, hereinafter referred to as the logo, on the attached list of product(s). Brand Name(s)* Applicant Relationship with the Brand* Owner of the Brand Co-Packer for the Brand Private Labeler Name Title Signature Date MM slash DD slash YYYY * Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands PhoneFax Website URL Email Twitter @ Instagram @ Facebook / Information submitted for certification purposes will be kept in strict confidentiality. Products Being submitted for RenewalUse + sign to add more rows.*ProductProduct Use + sign to add more rows. New Products being submitted for Certification Skip this section if no new products are being submitted for certification at this time. You can always submit a new product at a later time. Product Name Please use one row per supplier. Use + sign to add more rows.Please use one row per supplier. Use + sign to add more rows.IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product? Yes No Title *IngredientsSupplierSupplier email / phone Extra Notes: Processing Methods Information regarding processing methods and location must be detailed. List any cleaning methods for shared machinery with grains, legumes, and dairy. Note: Use of shared machinery does not disqualify products.Processing Methods Information regarding processing methods and location must be detailed. List any cleaning methods for shared machinery with grains, legumes, and dairy. Note: Use of shared machinery does not disqualify products. UPC Codes UPC Codes for Products meeting Paleo Certification Standards are shared with Interested parties such as Retailers and Industry Analysts once the Certification Agreement is completed.Product NameProduct CategoryUPC Code Annual Licensing FeesLicensing fees are assessed by companies’ gross annual revenues. CHOOSE ANNUAL, BI-ANNUAL, OR TRI-ANNUAL OPTION NEW! Get a 2-year Licensing Option at a 10% discount, or a 3-year Licensing Option at a 20% discount!* CHOOSE ANNUAL, BI-ANNUAL, OR TRI-ANNUAL OPTION NEW! Get a 2-year Licensing Option at a 10% discount, or a 3-year Licensing Option at a 20% discount! Annual Bi-Annual Tri-Annual Fee Band I II III IV V VI Annual Revenues Up to $100,000 Up to $500,000 Up to $1,000,000 Up to $5,000,000 Up to $10,000,000 More than $10,000,000 Annual Fee $1000 $1250 $1500 $1750 $2000 $2250 1. Please indicate your Fee Band:* I II III IV V VI Save time and 10% with a 2 year Licensing Option! Fee Band I II III IV V VI Annual Revenues Up to $100,000 Up to $500,000 Up to $1,000,000 Up to $5,000,000 Up to $10,000,000 More than $10,000,000 Annual Fee $1800 $2250 $2700 $3150 $3600 $4050 1. Please indicate your Fee Band:* I (save $200.00) II (save $250.00) III (save $300.00) IV (save $350.00) V (save $400.00) VI (save $450.00) Save time and 20% with a 3 year Licensing Option! Fee Band I II III IV V VI Annual Revenues Up to $100,000 Up to $500,000 Up to $1,000,000 Up to $5,000,000 Up to $10,000,000 More than $10,000,000 Annual Fee $2400 $3000 $3600 $4200 $4800 $5400 1. Please indicate your Fee Band:* I (save $600.00) II (save $750.00) III (save $900.00) IV (save $1,050.00) V (save $1,200.00) VI (save $1,350.00) Calculating License Options Base Licensing Fee: 1. Annual/ 2 Year/ 3 Year Fee Band Total: Price: $0.00 Certified Paleo Application Rush Orders: There is a $500 dollar rush fee for companies wishing to have their products rushed through the certification process within 10 business days and a $1,000 dollar rush fee for companies with same-day rush orders. This is not available to companies that submit more than 5 products to be reviewed at once. The rush fee does not guarantee that all applications can be rushed through as the process depends on the company and supplier’s ability to supply needed information in a timely manner. A refund of the rush fee with be issued if the process cannot be rushed for the selected period. 2. 10 Business Day Rush Request (additional $500) YES NO 3. Same-Day Rush (additional $1,000) YES NO More Than 10 Products: Certification for up to 10 products are included in the standard certification, each additional product is $30.00. TOTAL: $0.00 NOTE: Signature Required BelowPlease send your completed application via snail mail or email and allow approximately 6-8 weeks for the certification process to be completed. If you have a question about the status of your application, please send an email to info@paleofoundation.org PLEASE NOTE: Submitting this application does not grant authorization for the use of the “Certified Paleo” logo until the application is approved. Unauthorized use of the “Certified Paleo” Logo is a violation of federal Trademark Laws. * I agree to the above statement. All information in this application is accurate as of the date submitted. * I agree to Paleo Foundation Terms & Conditions and Privacy Policy. Applicant Signature Name of Company Date MM slash DD slash YYYY Payment MethodPayPal CheckoutCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name
