# Here is your signed document Balchem TLA QUE

Source: https://femstate.me/docs/here-is-your-signed-document-balchem-tla-que.md · Updated: 2026-09-10

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Human Nutrition & Health | Animal Nutrition & Health | Specialty Products
5 Paragon Drive
Montvale, NJ 07645 p. 845.326.5600
www.balchem.com f. 845.326.5702
Albion Albion Gold Medallion Creatine MagnaPower
TRAACS Calci-K VitaCholine VitaShure
K2VITAL OptiMSM Optifolin+
Ferrochel
Balchem TLA Questionnaire
1. Counterparty Entity Name: *Registered or official entity name only.
2. Counterparty Registered or Principal Business Address: *Must be legal, registered address.
Street: ___________________________________________________ City:
State / Province / Region: ________________________________ Zip / Postal Code:
Country: BBBBBBBBBBBBBBB__________________________________ Phone: ____________________________
3. State and Country of Registration or Incorporation: *Must include both.
4. If non-US entity, please provide EU VAT, GST or other registration number:
Please also attach a copy of a certificate of incorporation, certificate of good standing, or equivalent to confirm Counterparty is a registered company in the country in which it operates.
5. Counterparty Signee Name: Email Address:
6. What contract format does the customer accept? Adobe Sign Word Doc for Red-line
7. Principal Owner’s name and Country/State of Residence: * If a public company, name of CEO.
_____________________________________________________________________________________________________
8. Trademark(s) to be licensed:
9. Account Manager: ___________________________________________________________________________
10. What is the Customer’s brand name of the product that will be using the Trademark? i.e. One
A Day
11. What is the Customer’s specific product name that will utilize the Trademark? i.e. Women’s 50+
Healthy Advantage Multivitamin
12. Website URL: ________________________________________________________________________________
TLA Questionnaire | Page 1 of 2James Pollett221 E 4th STE 2300 CINCINNATI
N/A
Andrea Plaut
OHIO, UNITED STATES
X
FEMSTATE™ RESET
FEMSTATE™
Femstate LLC
45202
ANDREA PLAUT / UNITED STATES / OHIO
UNITED STATES 5135921801
OHIO
andreaplaut79@gmail.com
WWW.FEMSTATE.ME
X
Human Nutrition & Health | Animal Nutrition & Health | Specialty Products
5 Paragon Drive
Montvale, NJ 07645 p. 845.326.5600
www.balchem.com f. 845.326.5702
13. Where will the trademarks be used? i.e. Supplement Facts / Packaging / Marketing Materials
14. Ingredients being used:
15. What category does the brand participate in? Choose all applicable
Food Drug & Mass General Wellness On-Line MLM
Specialty Retailer Sports Nutrition Practitioner Pharmaceutical
16. Countries where product will be sold (for information only)
17. Does the customer work with a contract manufacturer? YES NO
Contract manufacturer information:
Name: Site Address: ________________________ Website: Phone:
Name: Site Address: ________________________ Website: Phone:
Name: Site Address: ________________________ Website: Phone:
Name: Site Address: ________________________ Website: Phone:
Name: Site Address: ________________________ Website: Phone:
18. Is the contract manufacturer purchasing raw materials on your behalf? YES NO
Completed by Approved by
Account Manager Director of Sales
Date Date
TLA Questionnaire | Page 2 of 2James PollettX
Iron (as Ferrous Bisglycinate Chelate Ferrochel(R) 18mg
X
UNITED STATES
Product Packaging / Supplement Facts / Website /
Marketing Materials FOR FEMSTATE™ RESET
X
MAKERS NUTRITION
X8/31/2026