Form 2904-1 Application for Certification

Form 2904-1 FORM APPROVED

(00-00) OMB NO. 0000-0000

UNITED STATES DEPARTMENT OF AGRICULTURE

DEPARTMENTAL ADMINISTRATION

APPLICATION FOR CERTIFICATION

VOLUNTARY LABELING PROGRAM FOR CERTIFIED BIOBASED PRODUCTS

The purpose of this form is to apply for certification to use the USDA Certified Biobased Product label under the Voluntary Labeling Program for Certified Biobased Products under the Federal BioPreferred Program, United States Department of Agriculture. A separate form must be used for each product. Provide the requested information and sign and date in the space on the last page. Your signature indicates that the information in this form is accurate and current as of the date shown in the space next to your signature.

1. Application Number (Agency Use Only)			2. Certification Number (Agency Use Only)
3. Manufacturer Information
a. Name	b. Mailing Address	c. Telephone Number
		d. Web site address
4. Application Preparer Information
a. Name
b. Mailing Address (if different from Item 3b)
c. Telephone Number (if different from Item 3c)			d. Email Address (if available)
5. Product Information
a. Brand Name(s)
b. Provide contact information for the third-party entity that determined the biobased content reported in Item 5b. Attach to this application documentation demonstrating that the entity is ISO 9001 conformant. Name of Entity: Contact Person: Telephone Number:
c. What is the biobased content of the product?
d. Product Grouping (check the applicable box below): 1.  Product is within one or more Designated Items under 7 CFR part 2902, subpart B. 2.  Product is a finished product that is not within a Designated Item under 7 CFR part 2902, subpart B and is not a mature market product. 3.  Product is an intermediate ingredient or feedstock that is not within a Designated Item under 7 CFR part 2902, subpart B.
e. If Box d1 is checked, enter the Designated Item Section(s) from 7 CFR part 2902, subpart B.
f. Provide a brief description of the uses for which the product is intended. Attach additional sheets if necessary.
6. Statement
I, the undersigned, hereby certify that the product identified in this application for which I seek approval to use the USDA Certified Biobased Product label is a biobased product as defined in 7 CFR § 2904.2 and meets the country of origin requirements specified in 7 CFR § 2902.4(b)(3). Furthermore, I, the undersigned, hereby agree to the following: a. After receipt of USDA approval of this application and prior to my first use of the label on the product identified in this application, the following information will be posted on the USDA Voluntary Labeling Web site (http://www.biopreferred.gov): (1) the product’s brand name (s), (2) contact information, as shown in Item 3 of this application, (3) the product’s biobased content, and (4) a hot link directly to the manufacturer’s Web site (if available); b. I further agree that documentation of analyses performed to support claims of environmental or human health benefits, life cycle cost, sustainability benefits, and product performance will be provided to USDA.

_________________________________________________________ _________________________

Signature Date

_________________________________________________________

Typed Name

_________________________________________________________

Title

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0000-0000. The time required to complete this information is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Form 2904-1 Page 2 of 2