We know you have choices. Thank you for choosing The Paleo Foundation again. Certified Paleo + Keto Certified Application Company Name(Company Name) seeks permission to use the "Certified Paleo" & “KETO Certified” Trademark, hereinafter referred to as the logo, 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 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 Paleo + 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. Product Name*Use + sign to add more rows.IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?*YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Diet Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Diet Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Diet Certification?YesNoTitle*IngredientsSupplierSupplier email / phone Extra Notes:Do you want to submit another product for Paleo + Keto Diet Certification?YesNoTitle*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 for Paleo or Keto Certification. UPC Codes UPC Codes for Products meeting Keto Certified Standards are shared with Interested parties such as Retailers and Industry Analysts once the Certification Agreement is completed.Product NameProduct CategoryUPC Code UntitledNutrition Facts Nutrition Facts must be submitted and analyzed for Keto Certification. Keto Diet Approved Products must meet ingredient and macronutrient standards. Upload Nutrition Facts Label* File upload 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 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $11,000 $12,000 1. Please indicate your Fee Band:*I (save $1,000.00)II (save $2,000.00)III (save $3,000.00)IV (save $4,000.00)V (save $5,000.00)VI (save $6,000.00)VII (save $7,000.00)VIII (save $8,000.00)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 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 1. Please indicate your Fee Band:*I (save $3,000.00)II (save $5,200.00)III (save $7,400.00)IV (save $9,600.00)V (save $11,800.00)VI (save $14,000.00)VII (save $16,200.00)VII (save $18,400.00) 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 $12,000 $14400 $16,800 $19,200 $21,600 $24,000 $26,400 $28,800 1. Please indicate your Fee Band:*I (save $6,000)II (save $9,600)III (save $13,200)IV (save $16,800)V (save $20,400)VI (save $24,000)VII (save $27,600)VIII (save $31,200) Calculating License Options Base Licensing Fee: 1. Annual/ 2 Year/ 3 Year Fee Band Total: Price: $0.00 Certified Paleo ApplicationTotal Do you want to submit another product. Price: $0.00 Paleo + Keto Certified Rush Orders: There is a $2000.00 rush fee for companies wishing to have their new products rushed through the Paleo and KETO certification process within 10 business days and a $3,000.00 rush fee for companies with 2 business day rush orders. Two business day rush is generally 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 the supplier’s ability to provide the documentation promptly. A refund of the rush fee will be issued if the process cannot be rushed for the selected period. 2. 10 Business Day Rush Request (additional $1000.00)YESNO 3. Two business day Rush (additional $3,000.00)YESNO 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 BelowProducts Being submitted for Renewal 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. * 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
