Company Name:

Street Name & Number (If applicable):

PO Box (If applicable):

City / Town:

State / Province:

Zip / Postal Code:

Country:

Phone Number:

Fax Number:

Primary Contact:

Email:

Number of Years in Business:

Website:

Volume

Total number of ocean containers and truckloads if from Canada and Mexico, imported into the US during the last full calendar year:

Volume:

Membership Status

New Membership Application

Renewal of Existing Membership

Terms and Responsibility

I certify that the information presented above is accurate to the best of my knowledge and is applicable to the conduct of the business of the company. I am a duly authorized representative of the company and declare the intent of the company to comply with the True Source Certified^® Standards of sourcing and traceability for Honey. I understand and agree that membership fees paid do not convey any rights of trademark use. It is understood that all information supplied on this document is totally confidential between the undersigned and TRUE SOURCE HONEY LLC.

Your Name:

Your Title: