Participation Form: 2021 CCBA Brewers Collaboration Participation Form Brewery Name* Brewery Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Brewery Website Primary Contact First and Last Name* Primary Contact Email* Primary Contact Cell Phone*Brewery Logoonly jpg or png formats acceptedMax. file size: 40 MB.Ingredient DonationsCrosby Hops has partnered with the CCBA to provide up to 44# of hops to participating brewers as supplies allow. They are able to provide the following varieties: Amarillo, Centennial, Cascade, Chinook, Columbus, GR Hallertau Blanc, Idaho 7, Meridian, Nugget, and Sterling. Are you interested in the using the hop donation for your beer?*If yes, you will be contacted by Crosby Hop Farm representative to coordinate the hop amount and variety you need. Yes No The Country Malt Group has partnered with the CCBA to provide Pure Idaho Pilsner Malt for brewers. Are you interested in the using the malt donation for your beer?*If yes, you will be contacted by CCBA and Country Malt to coordinate the malt amount you need. Yes No Donation Estimate + AgreementHow many BBLs do you expect to brew?* If applicable, what date do you expect to can the beer? When do you expect the beer to be in market? Please provide your best estimate on timing Based on your BBL production, please let us know how much money you expect to donate:*CCBA estimates net proceeds of each BBL of beer produced to be between $500-$1000 dollars. Donation Statement: You hereby represent and warrant to us, California Craft Brewers Association., that any and all proceeds from the sale of your CCBA Brewers Collaboration beer shall be donated to the California Craft Brewers Association. We shall be making representations to the public that all proceeds from all participating breweries shall be so donated. Your promise to us as to the accuracy of this representation and actions undertaking to ensure compliance are of paramount importance and strictly required for all parties to be in compliance with required laws, rules, and regulations.Donation Statement* I agree Name AgreementName Statement: This trademark License agreement (this “Agreement”), is entered into by and between CCBA and the undersigned (the “Licensee”). CCBA has common law rights in the mark “CCBA BREWERS COLLABORATION” (the “Mark”) and has applied for such mark with the United States Patent and Trademark Office (“USPTO”), Serial Number 90576300. Licensee hereby acknowledges and agrees that CCBA is owner of the Mark, the validity of the Mark, and the goodwill associated therewith. Licensor hereby grants to Licensee, on the terms and conditions of this Agreement, the non-exclusive, revocable license to use the Mark for the sole purpose of producing, marketing, and distributing a beer named or prominently including the name “CCBA Brewers Collaboration” to raise money for the CCBA (the “Products”). Licensee agrees that it shall acquire no rights or ownership in the Mark aside from the revocable license herein, and hereby agrees not to challenge the validity, ownership, use or registration of the Mark. Licensee may not grant any sublicenses to any third party without prior express written consent of the Licensor. Licensee shall be solely responsible for the manufacture, sale, and distribution of any Products or services under this License and will bear all related costs associated therewith. This Agreement, and license created hereunder, commences on the date set forth below, and shall automatically terminate on the earlier of written notice thereof to Licensee from Licensor, or October 31st, 2021. This Agreement does not create any form of partnership, joint venture, or any other relationship other than that of a licensor and licensee. The Agreement is governed by the laws of the State of California as if applied to transactions taking place wholly within California between California Residents. Licensee hereby agrees that the proceeds of any sales of its Products using the Mark shall be distributed and contributed to the CCBA.Name Statement* I agree Today's Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.