Free untitled - Federal

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

Form Approved: OMB N0. 0910-0030.

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

TYPE OF SUBMISSION:

ORIGINAL

AMENDED

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

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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 2. 9 - DIGIT CAS NO. 3. TYPE OF ACTION 7. BASE NAME OR TRADE NAME MATERIAL 4. DATE OF ACTION 8. COMPANY NAME 5. CONF

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6. BASE CPIS NO.

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1. COMMON, USUAL, OR CHEMICAL NAME

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02

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3. TYPE OF ACTION 7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION 8. COMPANY NAME

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1. COMMON, USUAL, OR CHEMICAL NAME

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2. 9 - DIGIT CAS NO. 6. BASE CPIS NO.

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07

2. 9 - DIGIT CAS NO. 6. BASE CPIS NO.

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2. 9 - DIGIT CAS NO. 6. BASE CPIS NO.

3. TYPE OF ACTION 7. BASE NAME OR TRADE NAME MATERIAL

4. DATE OF ACTION 8. COMPANY NAME

5. CONF

FORM FDA 2512a (6/09)

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Previous Edition is Obsolete.

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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)