We hear you have a new product!Great! Let's get started! We hear you have a new product!Great! Let's get started! Company Information Company Name (Company Name) seeks permission to use the “Certified Paleo” 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 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 PhoneWebsite URL Email Products Being submitted for Certification 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: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 new products have been approved.Product NameProduct CategoryUPC Code Certification Programs Select the following programs that you are applying for.I am applying for:* Select All CERTIFIED PALEO KETO CERTIFIED GRAIN-FREE GLUTEN-FREE RUSH OPTIONS For new products that require expedited processing, rush options are available. RUSH OPTIONS* NO RUSH FREE (4-6 week turnaround) 10 BUSINESS-DAY RUSH ($1,000) 2 BUSINESS-DAY RUSH ($2,000) TOTAL TOTAL $0.00 NOTE: Signature Required BelowPLEASE 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. 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
