Form 2512a Cosmetic Product Ingredient

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)
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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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

FORM FDA 2512a (6/09) (BACK)

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