Form D

CertiPUR-US^® Shredded Foam Application | Form D 2027 Directory

This Application Form should only be completed after review of the CertiPUR-US^® Shredded Foam Policy. Written approval from the Alliance for Flexible Polyurethane Foam (AFPF), which manages the CertiPUR-US^® program, is required before any Applicant (or their customers) may use the CertiPUR-US^® mark or name on any product containing shredded foam. For purposes of this Application Form, “Applicant” means the entity seeking approval from AFPF to use the CertiPUR-US^® mark or name in connection with products containing shredded foam. This form identifies the Applicant’s current CertiPUR-US^® status and collects the information needed for AFPF review and audit coordination.

Applicant Declarations and Status

The Applicant must promptly notify the AFPF in writing and submit an updated Application Form if any information provided in this Application Form changes. Failure to update and reapply as required may result in denial, suspension, or revocation of approval to use the CertiPUR-US^® mark and name.

A. Applicant Status Declaration

Check the one statement that best describes the Applicant’s current status with respect to the CertiPUR-US^® Program status and shredded foam sourcing arrangement: *

Participating Foam Producer — The Applicant pours or produces flexible polyurethane foam, is already approved as a participating foam producer in the CertiPUR-US® Program and seeks approval to use the CertiPUR-US® mark or name on its own finished products containing shredded foam.

Registered Manufacturer — The Applicant is registered with CertiPUR-US® to use the CertiPUR-US® name, logo, or related terms; does not itself pour or produce the foam at issue; and purchases pre-shredded foam or foam it shreds itself in house from one or more Participating Foam Producers or Participating Foam Suppliers for use in finished products.

Registered Retailer — The Applicant is registered with CertiPUR-US® to use the CertiPUR-US® name, logo, or related terms; and re-sells products made with shredded foam that are produced by a Registered Manufacturer or Participating Foam Producer (who has registered with the CertiPUR-US® shredded foam policy) and labeled under the retailer’s own name, brand or private label.

Email Contact Contact

Program Status (copy) *

Participating Foam Producer
Registered Manufacturer
Registered Retailer

B. Facility Location, Audit Contact Declaration, and Fee Acknowledgement (Registered Manufacturers Only)

Complete this section only if the Applicant selected Registered Manufacturer in Section A.

C. Supplier Declaration

Complete this section only if the Applicant selected Registered Manufacturer or Registered Retailer in Section A.

D. Foam Family Declarations

What type of CertiPUR-US^® certified foam are you shredding, purchasing to shred, or obtaining in a finished product that is made with shredded foam? *

E. Product(s) Using Shredded Foam Declaration

Check all product categories that will contain shredded foam bearing, or intended to bear, the CertiPUR-US^® mark or name: *

F. Applicant Certification and Acknowledgement

Applicant (Company Name) *

Company Email Address *

Company Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Authorized Representative Signature *

By signing this Application Form, the Applicant certifies that it has read, understands, and agrees to comply with and be fully bound by the CertiPUR-US® Shredded Foam Policy, all applicable CertiPUR-US® Program requirements, Technical Guidelines, and any other obligations referenced or incorporated herein. The Applicant further certifies that all information provided in this Application Form is true, accurate, and complete in all material respects as of the date of signature. The Applicant acknowledges that any material misstatement or omission, failure to update declared information, failure to cooperate with an audit or inspection, or, if applicable, failure to pay applicable Program fees may result in denial of approval or suspension or revocation of the right to use the CertiPUR-US® mark.

Authorized Representative Name *

Authorized Representative Signature

Clear Signature

Authorized Representative Title *

Authorized Representative Email *

Date *

Email (for copy of form)

Enter an email address to receive a copy of your form submission

Email Copy

By submitting this document, I give permission to CertiPUR-US® program administrators to email periodic program updates.

Form D

Form D

CertiPUR-US® Shredded Foam Application | Form D 2027 Directory

Applicant Declarations and Status

A. Applicant Status Declaration

B. Facility Location, Audit Contact Declaration, and Fee Acknowledgement (Registered Manufacturers Only)

C. Supplier Declaration

D. Foam Family Declarations

E. Product(s) Using Shredded Foam Declaration

F. Applicant Certification and Acknowledgement

CertiPUR-US^® Shredded Foam Application | Form D 2027 Directory