Form A

Form A

CertiPUR-US® Program Supplier Verification Form A

If you are unable to fill out the form below, download the document, print, complete, sign, scan, and send as an attachment in an email to forms@certipur.us.

  • Please fill out this form on behalf of any of the companies you supply certified foam or products containing certified foam to that want to register for permission to use the CertiPUR-US® trademarked name/logo/mark.
  • There is no cost to you or your customer to register. Once registered, your customer’s company and brands will be listed in the CertiPUR-US® online directory.
  • Form A is used by CertiPUR-US® administrators, in strict confidence, to verify the supply chain and maintain the credibility and integrity of the program.

Section 1: About Your Customer

Please provide information about your customer who is requesting permission to use the CertiPUR-US® name/logo/mark.
Please include a country code if applicable.
Please include an extension if applicable

Section 2: Statement From Supplier/Distributor/Reseller

The company I am authorized to represent is listed on either the Foam Producer List or the Participating Company List. *

Note: If your company is not listed in our online directory, your company must register before you can submit a Form A on behalf of your customer.

Section 3: Statement of Verification

Use the fields below to complete and consent to this statement.

“I hereby verify that Name of customer company is purchasing one or more of the certified foam families checked below from the company I am authorized to represent: Name of supplier/distributor/reseller (your company name).”

Type of foam(s) (check all that apply):

Clear Signature
Please use your cursor to sign if you are on a desktop.
Scroll to Top