06-022 Code Vt. R. 06-031-022-X
Appendix A Sworn Statement Form
Certifying Food NOT Produced with Genetic Engineering
NAME OF MANUFACTURER OR PRODUCER: _____________________________________________
ADDRESS: ________________________________
CITY: __________________ STATE ____________
ZIP CODE: ________________
AGENT SIGNING ON BEHALF OF MANUFACTURER: _________
AGENT CONTACT PHONE NUMBER: ________
AGENT EMAIL: _____________________________
NAMEOFPRODUCT(S): _______________
UPC CODE, LOT NUMBER OR OTHER IDENTIFICATION NUMBER: _____________________
I, _______________________ , as the authorized agent of the Manufacturer/Producer listed above, hereby depose and state as follows:
The above 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.
I declare or affirm, under penalty of perjury, that the above statement is true and correct to the best of my knowledge.
Agent Signature: ______________ Date: __________
Agent Printed Name: _____________
06-022 Code Vt. R. 06-031-022-X
July 1, 2016 Secretary of State Rule Log #15-011
STATUTORY AUTHORITY: 2013, No. 120 (Adj. Sess.) § 3