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pdfDEPARTMENT 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)
Read Instruction Booklet Before Completing. Type entries in CAPITAL LETTERS.
Expiration Date: February 29, 2012.
See Burden Statement on Reverse of Part I.
ORIGINAL
AMENDED
FOR FDA USE ONLY ON ORIGINAL SUBMISSIONS
FDA CPIS NO.
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
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
02
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
3. TYPE OF ACTION
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
03
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
3. TYPE OF ACTION
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
04
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
3. TYPE OF ACTION
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
05
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
3. TYPE OF ACTION
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
06
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
3. TYPE OF ACTION
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
07
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
3. TYPE OF ACTION
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
08
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
3. TYPE OF ACTION
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
09
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
3. TYPE OF ACTION
B
7. BASE NAME OR TRADE NAME MATERIAL
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
1. COMMON, USUAL, OR CHEMICAL NAME
10
3. TYPE OF ACTION
2. 9 - DIGIT CAS NO.
6. BASE CPIS NO.
F
FORM FDA 2512a (6/09)
B
7. BASE NAME OR TRADE NAME MATERIAL
Previous Edition is Obsolete.
4. DATE OF ACTION
5. CONF
8. COMPANY NAME
This Form Must be Securely Attached to Form FDA 2512.
PSC Graphics: (301) 443-1090
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FORM FDA 2512a (6/09) (BACK)
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| File Type | application/pdf |
| File Title | FORM FDA 2512a |
| Subject | Cosmetic Product Ingredient Statement |
| Author | PSC Graphics |
| File Modified | 2011-02-25 |
| File Created | 2009-06-18 |