Statement Form Certifying Food NOT Produced with Genetic Engineering

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The below named product(s) were made or grown from food or seed that has not been knowingly or intentionally produced with genetic engineering and has been segregated from and has not been knowingly or intentionally commingled with food that may have been produced with genetic engineering. Manufacturer/Producer shall indemnify ProSource for any and all claims related to any inaccuracy of the above statement.

I declare or affirm, under penalty of perjury, that the above statement is true and correct to the best of my knowledge.

Name of Products: *

Seller/Company Name *

Seller/Company Address *

Name of representative *

Title of representative *

As a representative of the above seller, are you authorized to enter into commitments such as this on their behalf? *

Yes

As an authorized representative for the seller, "I" do hereby "AGREE" to the terms of this agreement. *

By checking this box the above listed representative commits that the seller acknowledges fully and completely the terms and conditions of the above hold harmless agreement. Furthermore, the seller swears to abide by and honor these terms in their entirety.

Required

Dated this day *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of Golden West Produce.