FDA2512a Cosmetic Product Ingredient Statement

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
COLLEGE PARK, MD 20740-3835

Form Approved: OMB N0. 0910-0030.

TYPE OF SUBMISSION:

COSMETIC PRODUCT INGREDIENT STATEMENT
(In accordance with 21 CFR 720)

Expiration Date: December 31, 2008
See Burden Statement on Reverse of Part I.

ORIGINAL

FOR FDA USE ONLY ON ORIGINAL SUBMISSIONS
FDA CPIS NO.

Read Instruction Booklet Before Completing. Type entries in CAPITAL LETTERS.

AMENDED

FILING DATE

F

NOTE: This report is authorized by Public Law 21 U.S.C. 371(a); 21 CFR 720. While you are not required to respond, your cooperation is needed to make the results
of this voluntary program comprehensive, accurate, and timely.
INGRED NO.

1. COMMON, USUAL, OR CHEMICAL NAME
3. TYPE OF ACTION

2. 9 - DIGIT CAS NO.

01

6. BASE CPIS NO.

F

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

1. COMMON, USUAL, OR CHEMICAL NAME

02

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

F

1. COMMON, USUAL, OR CHEMICAL NAME

03

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

F

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

1. COMMON, USUAL, OR CHEMICAL NAME

04

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

F

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

1. COMMON, USUAL, OR CHEMICAL NAME

05

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

F

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

1. COMMON, USUAL, OR CHEMICAL NAME

06

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

F

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

1. COMMON, USUAL, OR CHEMICAL NAME

07

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

F

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

1. COMMON, USUAL, OR CHEMICAL NAME

08

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

F

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

1. COMMON, USUAL, OR CHEMICAL NAME

09

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

F

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B

1. COMMON, USUAL, OR CHEMICAL NAME

10

2. 9 - DIGIT CAS NO.

3. TYPE OF ACTION

6. BASE CPIS NO.

F
FORM FDA 2512a (6/06)

7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION

5. CONF

8. COMPANY NAME

B
Previous Edition is Obsolete.

This Form Must be Securely Attached to Form FDA 2512.

PSC Graphics: (301) 443-1090

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Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden to:
DHHS/FDA/CFSAN
Office of Cosmetics and Colors
Voluntary Cosmetic Registration Program (HFS-125)
5100 Paint Branch Parkway
College Park, MD 20740-3835

FORM FDA 2512a (6/06) (BACK)

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