USDA Organic & Non-GMO Project Verified

Participant Information:

USDA Organic & Non-GMO Project Verified

Company Name:

Primary Contact Person:

Name: Phone: E-mail:

Address:

Street:

City: State or Province: Zip: Country:

Are you applying for Organic Certification, Non-GMO Project Verification, or both?

- USDA Organic - Non-GMO Project Verified - Both

Product Information:

Total number of product(s) submitted for evaluation:

Complete table below or provide equivalent information on a separate sheet:

Product: / Brand Name(s):

Which, if any of the above referenced brands are not owned by your company (i.e., Private Labels)? Private Label Brands: OR - N/A NO PRIVATE LABEL PRODUCTION

For Non-GMO Project applicants only – attach complete list of ingredients used in all products: - ATTACHED OR - N/A ORGANIC APPLICANT ONLY

For Organic crop production only – how many total acres of land are dedicated to organic production? Organic acreage: OR - N/A NO ORGANIC CROP PRODUCTION

Facility Information:

How many facilities are used to produce the product(s) submitted for evaluation?

Do you own each facility, or does each facility produce your products under a pre-existing contractual arrangement?

- OWN - CONTRACT - BOTH

Are all facilities dedicated to Certified Organic and/or Non-GMO Project Verified compliant production?

- YES - NO

Activity: (check all that apply)

Non-GMO Project Standard V13 §II.C

- Agricultural Production - Seeds and Crops [includes farm production, harvest, and post-harvest handling and storage on farm or farm-related activities]

- Handling [includes any form of post-harvest movement, storage, transformation, or labeling of goods along the entire chain of custody from seed to consumer, except for products enclosed in final retail packaging]

- Storage [includes all links in the chain of custody from seed to finished product]

- Distribution [may or may not involve physical handling of goods]

- Processing/Manufacturing [includes all movements, storage, transformation, combining, or labeling of goods within any given production facility, including restaurants or other food service facilities; manufacturing specifically involves the combination of inputs to make the final product sold by the operation in question]

- Packaging and Labeling [includes any and all events where the package or labeling of goods is altered]

Participant Declaration:

I affirm I am a legally authorized representative of the Participant and all statements made in this application are truthful and correct. I understand acceptance of this application in no way implies granting of certification and/or product verification by SCS.

Name or Signature of Participant Representative:

Title: Date:

Submit completed program application/participant information profile to:

Ned Halaby

SCS Global Services

2000 Powell Street Suite 600

Emeryville, CA 94608

phone: 1-510-452-6822

www.scsglobalservices.com