We know you have choices. Thank you for choosing The Paleo Foundation again. 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). NameTitleSignatureDate Date Format: 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 PhoneFaxWebsite URL Email Twitter @Instagram @Facebook /How did you hear about us?GoogleReferer WebsiteInstagramTwitterOtherReferred 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 RenewalDo you want to submit another product?*YesNo 1) Product Name *Please use one row per supplier. Use + sign to add more rows.IngredientsSupplierSupplier email / phone 1) Upload Nutrition Facts Label for Keto Certification Calculation Extra Notes: Do you want to submit another product?*YesNo2) Product NameIngredientsSupplierSupplier email / phone 2) Upload Nutrition Facts Label for Keto Certification Calculation Extra Notes:Do you want to submit another product?YesNo3) Product Name 3) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo4) Product Name 4) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo5) Product Name 5) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo6) Product Name 6) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo7) Product Name 7) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo8) Product Name 8) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo9) Product Name 9) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo10) Product Name 10) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo11) Product Name 11) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo12) Product Name 12) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo13) Product Name 13) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo14) Product Name 14) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo15) Product Name 15) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo16) Product Name 16) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo17) Product Name 17) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo18) Product Name 18) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo19) Product Name 19) Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo20) Product Name 20 Upload Nutrition Facts Label for Keto Certification Calculation IngredientsSupplierSupplier email / phone Extra Notes:New Products Being submitted for Grain-free and KETO CertificationSkip 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?*YesNo 1) Product Name *Use + sign to add more rows.IngredientsSupplierSupplier email / phone 1) Upload Nutrition Facts Label for Keto Certification Calculation Extra Notes: Do you want to submit another product?*YesNo2) Product Name*IngredientsSupplierSupplier email / phone 2) Upload Nutrition Facts Label for Keto Certification Calculation Extra Notes:Do you want to submit another product?YesNo3) Product Name 3) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo4) Product Name 4) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo5) Product Name 5) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo6) Product Name 6) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo7) Product Name 7) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo8) Product Name 8) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo9) Product Name 9) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo10) Product Name 10) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo11) Product Name 11) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo12) Product Name 12) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo13) Product Name 13) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo14) Product Name 14) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo15) Product Name 15) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo16) Product Name 16) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo17) Product Name 17) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo18) Product Name 18) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo19) Product Name 19) Upload Nutrition Facts Label for Keto Certification Calculation *IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNo20) Product Name 20 Upload Nutrition Facts Label for Keto Certification Calculation *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, 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 NameProduct CategoryUPC Code Tannins and Active Enzymes Please list the products which contain tannins or active enzymes below. Product NameTanninsActive Enzymes Licensing OptionsLicensing 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 Year2 Year1 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)YESNO 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 SignatureName of CompanyDate Date Format: MM slash DD slash YYYY