Free untitled - Federal

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

Form Approved: OMB N0. 0910-0030.
TYPE OF SUBMISSION: ORIGINAL

Expiration Date: February 29, 2012. See Burden Statement on Reverse of Part I.
AMENDED DISC BASE

COSMETIC PRODUCT INGREDIENT STATEMENT
(In accordance with 21 CFR 720) Read Instruction Booklet Before Completing. Type entries in CAPITAL LETTERS.

FOR FDA USE ONLY ON ORIGINAL SUBMISSIONS
FDA CPIS NO. FILING DATE

F
11. NAME OF MANUFACTURER / PACKER (Private Labeler)

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. 01. NAME OF MANUFACTURER / PACKER / DISTRIBUTOR (On Label)

02. KIND OF BUSINESS

MFR

PKR

DISTR 12. NAME OF PARENT COMPANY (If any)

03. NAME OF PARENT COMPANY (If any)

04. COMPLETE MAILING ADDRESS:

13. COMPLETE MAILING ADDRESS:

14. IS THIS STATEMENT FILED BY COMPANY 01 OR COMPANY 11? (Please check one) COMPANY 01 COMPANY 11 BRAND NO. 16. BRAND NAME OF COSMETIC PRODUCT

15. PRODUCT CATEGORY CODE:

17. TYPE OF ACTION

18. DATE OF ACTION

01

02

03

04

05

06

07

08 19. TYPE NAME AND TITLE OF AUTHORIZED INDIVIDUAL 20. TELEPHONE NO. 21. SIGNATURE AND DATE

FORM FDA 2512 (6/09) CONTINUE COSMETIC PRODUCT INGREDIENT STATEMENT ON FORM FDA 2512a
EF
PSC Graphics: (301) 443-1090

Page

of

Pages

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: Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer (HFA-710) 5600 Fishers Lane Rockville, MD 20857
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

FORM FDA 2512 (6/09) (BACK)

OFFICIAL RECEIPT
DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION COLLEGE PARK, MD 20740-3835 BRAND NAME OF COSMETIC PRODUCT

FOR FDA USE ONLY

1. 2.

COSMETIC PRODUCT INGREDIENT STATEMENT
TO:

FDA CPIS NO.1 FILING DATE

F

THIS STATEMENT IS COMPLETE INCOMPLETE

(If Incomplete, Form FDA 2515 is attached) 1 Assignment of an FDA Cosmetic Product Ingredient Statement Number (FDA CPIS No.) does not denote in any way approval of the firm or the cosmetic product by the Food and

Drug Administration. Any representation in labeling or advertising that creates an impression of official approval because of such filing or such number will be considered misleading. 21 CFR 720.9

FORM FDA 2512 (6/09)