2019 Grandfather Band V Renewal Form 63 • Paleo Foundation

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Paleo Certification Renewal Application
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
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 /
Information submitted for certification purposes will be kept in strict confidentiality.
Products Being submitted for Renewal
*
Product 1 Product 2

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.
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
Ingredients Supplier Supplier email / phone
Extra Notes:
Do you want to submit another product?
- Yes
- No
Title
*
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, 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 Name Product Category UPC Code
Annual Licensing Fees
Licensing 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.
- 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 $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 $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.
Discount
Price: $0.00
Discounts:

Companies Renewing on or before the end of their agreement are eligible for an additional 10% discount
4. Company Renewing on Time?
- YES
- NO
TOTAL:
$0.00
NOTE: Signature Required Below
Please 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
Date Format: MM slash DD slash YYYY

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