We know you have choices. Thank you for choosing The Paleo Foundation again. KETO Certification Renewal Application Company Name (Company Name) seeks permission to use the “KETO Certified” Trademark, hereinafter referred to as the logo, on the attached list of product(s). 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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.Processing Methods Information regarding processing methods and location must be detailed. 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 3, 2, OR 1 YEAR LICENSING OPTION Save time and money with a 3-year Paleo Certified Licensing Option at a 20% discount, or a 2-year Licensing Option at a 10% discount.* CHOOSE 3, 2, OR 1 YEAR LICENSING OPTION Save time and money with a 3-year Paleo Certified Licensing Option at a 20% discount, or a 2-year Licensing Option at a 10% discount. 3 year licensing 2 year licensing 1 year licensing Fee Band I II III IV V VI VII VIII 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 More than $20,000,000 More than $50,000,000 Annual Fee $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 1. Please indicate your Fee Band:* I II III IV V VI VII VIII Save time and 10% with a 2 year Licensing Option! Fee Band I II III IV V VI VII VIII 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 More than $20,000,000 More than $50,000,000 2-Year Fee $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 1. Please indicate your Fee Band:* I (save $600.00) II (save $800.00) III (save $1,000.00) IV (save $1,200.00) V (save $1,400.00) VI (save $1,600.00) VII (save $1,800.00) VIII (save $2,000.00) Save time and 20% with a 3 year Licensing Option! Fee Band I II III IV V VI VII VIII 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 More than $20,000,000 More than $50,000,000 3-Year Fee $7,200 $9,600 $12,000 $14,400 $16,800 $19,200 $21,600 $24,000 1. Please indicate your Fee Band:* I (save $1,800) II (save $2,400) III (save $3,000) IV (save $3,600) V (save $4,200) VI (save $4,800) VII (save $5,400) VII (save $6,000) 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 $2000 rush fee for companies wishing to have their products rushed through the certification process within 10 business days and a $3,000 rush fee for companies with two business 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 promptly. 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 $2,000) YES NO 3. 2 Business Day Rush (additional $3,000) YES NO More Than 10 Products: Certification for up to 10 products are included in the standard certification, each additional product is $50.00. TOTAL: $0.00 NOTE: Signature Required Below 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
