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Keto + Grain Free Certification Application
Company Name

(Company Name) seeks permission to use the “Grain Free Gluten Free” and "KETO Certified" Trademarks, hereinafter referred to as the 'logos', on the attached list of product(s).
Name
Title
Signature
Date
Date Format: MM slash DD slash YYYY
*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Website URL
Email
Twitter @
Instagram @
Facebook /
How did you hear about us?
Referred by: (Name and Contact info)
Information submitted for certification purposes of Keto and Grain Free Certification will be kept in strict confidentiality.
Products Being submitted for Renewal
Do you want to submit another product?*
- Yes
- No
1) Product Name
*
Please use one row per supplier. Use + sign to add more rows.
Ingredients Supplier Supplier email / phone
1) Upload Nutrition Facts Label for Keto Certification Calculation
Extra Notes:
Do you want to submit another product?*
- Yes
- No
2) Product Name
Ingredients Supplier Supplier email / phone
2) Upload Nutrition Facts Label for Keto Certification Calculation
Extra Notes:
Do you want to submit another product?
- Yes
- No
3) Product Name
3) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
4) Product Name
4) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
5) Product Name
5) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
6) Product Name
6) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
7) Product Name
7) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
8) Product Name
8) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
9) Product Name
9) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
10) Product Name
10) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
11) Product Name
11) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
12) Product Name
12) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
13) Product Name
13) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
14) Product Name
14) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
15) Product Name
15) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
16) Product Name
16) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
17) Product Name
17) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
18) Product Name
18) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
19) Product Name
19) Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
20) Product Name
20 Upload Nutrition Facts Label for Keto Certification Calculation
Ingredients Supplier Supplier email / phone
Extra Notes:
New Products Being submitted for Grain-free and KETO 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.
Do you want to submit another product?*
- Yes
- No
1) Product Name
*
Use + sign to add more rows.
Ingredients Supplier Supplier email / phone
1) Upload Nutrition Facts Label for Keto Certification Calculation
Extra Notes:
Do you want to submit another product?*
- Yes
- No
2) Product Name
*
Ingredients Supplier Supplier email / phone
2) Upload Nutrition Facts Label for Keto Certification Calculation
Extra Notes:
Do you want to submit another product?
- Yes
- No
3) Product Name
3) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
4) Product Name
4) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
5) Product Name
5) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
6) Product Name
6) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
7) Product Name
7) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
8) Product Name
8) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
9) Product Name
9) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
10) Product Name
10) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
11) Product Name
11) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
12) Product Name
12) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
13) Product Name
13) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
14) Product Name
14) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
15) Product Name
15) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
16) Product Name
16) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
17) Product Name
17) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
18) Product Name
18) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
19) Product Name
19) Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
20) Product Name
20 Upload Nutrition Facts Label for Keto Certification Calculation
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Processing Methods

Information regarding processing methods and location must be detailed. List any cleaning methods for shared machinery with grains, and pseudograins. Note: Use of shared machinery does not disqualify products from KETO and Grain Free Certification.
UPC Codes

UPC Codes for Products meeting Grain Free Gluten Free Certification Standards are shared with Interested parties such as Retailers and Industry Analysts once the Certification Agreement is completed.
Product Name Product Category UPC Code
Tannins and Active Enzymes

Please list the products which contain tannins or active enzymes below.
Product Name Tannins Active Enzymes
Licensing Options
Licensing fees are assessed by companies’ gross annual revenues.
*

CHOOSE 3, 2, OR 1 YEAR OPTION
Save time and money with a 3-year Licensing Option at a 20% discount, or a 2-year Licensing Option at a 10% discount.
- 3 Year
- 2 Year
- 1 Year
- 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
- $6,000
- $7,000
- $8,000
- $9,000
- $10,000
- $11,000
- $12,000
- $13,000
1. Please indicate your Fee Band:*
- I (save $1,000)
- II (save $1,000)
- III (save $1,000)
- IV (save $1,000)
- V (save $1,000)
- VI (save $1,000)
- VII (save $1,000)
- VIII (save $1,000)
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
- $10,800
- $12,600
- $14,400
- $16,200
- $18,000
- $19,800
- $21,600
- $23,400
1. Please indicate your Fee Band:*
- I (save $3,200.00)
- II (save $5,400.00)
- III (save $7,600.00)
- IV (save $9,800.00)
- V (save $12,000.00)
- VI (save $14,200.00)
- VII (save $16,400.00)
- VII (save $18,600.00)
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
- $14,400
- $16,800
- $19,200
- $21,600
- $24,000
- $26,400
- $28,800
- $31,200
1. Please indicate your Fee Band:*
- I (save $6,600)
- II (save $10,200)
- III (save $13,800)
- IV (save $17,400)
- V (save $21,000)
- VI (save $24,600)
- VII (save $28,200)
- VIII (save $31,800)
Calculating License Options
Base Licensing Fees:
1. Annual/ 2 Year/ 3 Year Fee Band Total:
Price: $0.00
Lab Costs:

Please Read Carefully Lab evaluations include gluten and gliadin-competitive testing. The lab costs calculated on this form include shipping, handling, personnel, and quantity discounts offered (for more than 10 products). Lab Costs for products produced in one facility are calculated on the application. If products are produced at multiple facilities, lab analysis is required for each facility and a Paleo Foundation administrator must send an invoice.

If your product(s) has already been lab-tested for gluten content within the past year, please email the results to info@paleofoundation.org and a Paleo Foundation administrator will send an invoice for gliadin-competitive testing only for your Grain Free Certification.

Please answer the following questions carefully:
*
- I would like to pay for my lab tests now.
- I would like to be invoiced for my lab tests separately from this application.
- I have multiple production facilities for my products.
- I have products that have been lab-tested within the last year.
2. Grain Free Certification Lab Costs Calculations Total:
Price: $0.00
Certified Keto + Grain Free Application
Rush Options:

There is a $3,000.00 dollar rush fee for companies wishing to have their products rushed through the certification process within 10 business days. The 10-day rush option is not available to companies that submit more than 10 products to be reviewed at once. The rush fee does not guarantee that all applications can be rushed through, as the process depends on several factors outside of the Paleo Foundation locus of control. This includes the ingredient supplier's ability to provide the required information in a timely manner, as well as postal delays. A refund of the rush fee will be issued if the process cannot be rushed for the selected period.
3. 10 Business Day Rush Request (additional $3000)
- YES
- NO
More Than 10 Products:

Certification for up to 10 products are included in the standard Keto and Grain Free Certification. Each additional product is $50.00.
TOTAL:
$0.00
NOTE: Signature Required Below
*
- 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
Date Format: MM slash DD slash YYYY

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