Raw Material Supplier Form
Section 1 General Information
Product Name:
Supplier Product No.:
Country of Origin: Grade: (delete the irrelevant) technical, cosmetic, food, pharma, NA
Please provide Safety Data Sheet for United States and European Union.
Supplier Company Information Manufacturer Company Information
Name Name
Address Address
Phone Phone
Website Website
Section 2 Contact Information
Commercial Contact Technical Contact REACH Contact
Name
Address
Phone
Email
Purchasing Contact Regulatory Contact
Name
Address
Phone
Email
The below signature certifies that all the information supplied in this form is current, complete, and accurate. The
supplier understands that Milliken & Company is relying on Supplier’s certification to ensure Milliken & Company’s
compliance with applicable global legal requirements and regulations.
Name:
Phone:
Email:
Signature:
Date:
Section 3 Environmental Compliance
1* 2* 3* 4* 5* 6* 7*
Max SARA
Wt CAA CAA State CERCLA 302 SARA
Components CAS # % HAP VOC TAP CWA RQ (lbs) EHS 313
1
2
3
4
5
6
7
8
9
*see Appendix A for explanations
Total VOC’s by EPA method 24/24A (%):
Total VOC’s estimated based on product composition (%):
Section 4 Metals Analysis
(If the number you provide is the detection limit, please mark with *.)
Metal Max Value Metal Max Value Metal Max Value
Al Aluminum Sb Antimony As Arsenic
Ba Barium Be Beryllium Bi Bismuth
Cd Cadmium Cr Chromium Co Cobalt
Cu Copper Fe Iron Hg Mercury
Mg Magnesium Mn Manganese Ni Nickel
Pb Lead Se Selenium Ag Silver
Te Tellurium Tl Thallium Sn Tin
Zn Zinc
Rev #: Original Rev. Date: Page 2 of 10
Section 5 General Hazard and Compliance Information:
No Yes Details
RCRA Hazardous Waste? ☐ ☐ characteristic/waste code(s):
info
Is product hazardous under the ☐ ☐
OSHA HAZCOM standard?
SARA 311/312 Hazard? ☐ ☐ Please delete the hazards which do not apply to this
info product: acute/chronic/fire/pressure/reactive
DOT regulated? ☐ ☐ Proper shipping name:
info
Is the product compliant to CONEG? ☐ ☐
Is product EU Council Reg. EC No ☐ ☐
2037/2000 compliant?
Is the product or any components ☐ ☐ Substance:
regulated by California Proposition
info
65 (Prop 65)?
Is the product classified according to ☐ ☐
DSD (67/548/EEC), DPD
(1999/45/EC),and CLP (1272/2008)?
Is the product compliant to Directive ☐ ☐
2002/95/EC on the restriction of the
use of certain hazardous substances
in electrical and electronic
equipment (RoHS)?
Is the product compliant to Directive ☐ ☐
94/62/EC on packaging and
packaging waste?
Is the product compliant to Safety of ☐ ☐
Toys EN 71 part 3 and part 9?
Is the product compliant to the ☐ ☐
Cosmetics Directive 76/768/EC and
its subsequent amendments?
Does your product have any ☐ ☐ Please specify Monographs
approvals or certifications for US or info
EU Pharmacopoeia?
Is this product classified under UN- ☐ ☐ If yes, please specify.
GHS regulations?
Is this product classified under ☐ ☐
German Water Hazard (WGK)?
Please provide the ratings for the following categories:
Health Flammability Reactivity
Recommended Personal Protective Equipment:
Rev #: Original Rev. Date: Page 3 of 10
Section 6 Toxicological Data (as available)
Data Species Test Method
Ingestion LD50 (mg/Kg)
Inhalation LC50 (mg/Kg)
Respiratory Sensitizer
Eye Irritation / Damage
Dermal LD50 (mg/Kg)
Skin Corrosion / Irritation
Skin Sensitizer
Fish Tox LC50 (mg/L)
Daphnia LC50 (mg/L)
Mutagenicity
Carcinogenicity
Reproductive Toxicity
Subacute/Subchronic Toxicity
Biodegradability (aerobic &
anaerobic)
Octanol Water Partition
Coefficient Kow
Additional Data
Is the product tested on animals? ☐Yes ☐No
Section 7 International Chemical Substances Approvals (include impurities or by-products)
Australia – AICS
Canada- NDSL
China – IECSC
New Zealand –
Japan – ENCS
EU – ELINCS*
Taiwan - ECN
EU- EINECS*
Canada- DSL
Korea – ECL
Philippines –
US - TSCA
PICCS
NZIoC
Component CAS RN Wt%
* EC No.: _________
1) Is this product or any component subject to regulation by US EPA such as SNUR, PAIR, etc?
☐Yes ☐No If yes, please explain.
Rev #: Original Rev. Date: Page 4 of 10
Section 8 REACh Status
n y Comments
Pre-registered ☐ ☐
Registered ☐ ☐ If yes, Reg No.: If no, planned date:
Exempted ☐ ☐ Reason:
Uses Supported ☐ ☐
Use Description
Substances of Very High Concern (SVHC)
reference link: Candidate List
☐ Our product defined above does not contain any of the chemicals listed in the Candidate List (last update prior
to completion date of this form) of Substances of Very High Concern for Authorization stated in the REACH
Regulation (1907/2006/EC), in a concentration above 0.1%.
Please complete the table below for any components that are on the List of Substances of Very High Concern for
Authorization, last update prior to completion date of this form. Add lines as needed.
Name of Substance CAS No. EC No. Contents %
Classification, Labeling, and Packaging (CLP)
1) Has the material CLP classification and labeling been notified in accordance with Article 39 of
Classification, labeling, and packaging of substances of mixtures regulation 1272/2008?
☐Yes ☐No
If no, please state reason:
If yes, what is the hazard classification?
2) Does the product contain any substances which are classified as carcinogenic, mutagenic or reprotoxic,
category 1 or 2 in accordance with 67/548/EEC and its subsequent amendments or in accordance with
CLP Regulation No. 1272/2008 and its subsequent amendments? ☐Yes ☐No
3) Does the product contain any substances which are classified as carcinogenic, mutagenic or reprotoxic,
category 3 in accordance with 67/548/EEC and its subsequent amendments in accordance with CLP
Regulation No. 1272/2008 and its subsequent amendments? ☐Yes ☐No
Rev #: Original Rev. Date: Page 5 of 10
Section 9 Product Origin and Allergens
Does this product contain or is derived from any of the below?
Max
Y/N Substance CAS #
Amt
Genetically Modified
Organisms
Synthetic origin?
Mineral origin? Specify
Animal Origin? Specify
Contains BSE/TSE?
Plant Origin? Specify
Allergens:
Peanuts
Soy Beans
Milk
Eggs
Fish
Crustaceans
Tree Nuts
Wheat
Cereals w/gluten
Celery
Sesame Seed
Other- specify
Is product Kosher certified? ☐Yes ☐No
Is product Halal certified? ☐Yes ☐No
Rev #: Original Rev. Date: Page 6 of 10
Section 10 Substances of Concern
Does your product contain any of these substances of concern? Please explain any “yes” answers below the
table.
Y/N Max Amt Chemical name CAS #
Algaecide/Biocide
Alkyl phenols (straight chain) and their
ethoxylates
Aromatic amines
Aromatic hydrocarbons
Asbestos
Azo colorants/compounds
Bisphenol A
Brominated flame retardants (other than
PBB/PBDE)
Butylated Hydroxytoluene (BHT)
Canadian Challenge Substances
Defoamers
Diaryl Pigments
1,4-Dioxane
Dioxins/Furans (e.g. brominated/chlorinated)
Epoxy derivatives (e.g. BADGE, BFDGE,
NOGE)
Ethylene Oxide
Fluorochemicals
Formaldehyde or potential formaldehyde
releasers/donors
Halogens and their compounds
(e.g. brominated/chlorinated)
Mono- and Diethylene series glycol ethers
Naphthalene
Natural Latex
Nonyl phenol and nonyl phenol ethoxylates
Organotin Compounds
(Tributyl tin or Triphenyl tin compounds)
Ortho Phenyl Phenol
Ozone Depleting Substances, Class I
Ozone Depleting Substances, Class II
Paradiclhorbenzene (PDCB)
Perfluorooctanoic Acid (PFOA)
Phthalates
Polybrominated biphenyls (PBB)
Poly brominated diphenyl ethers/oxides
(PBDE/PBDO)
Polybrominated Flame Retardants (PBFR)
Polychlorinated biphenyls (PCB)
Polychlorinated terphenyls (PCT)
Polychlorinated naphthalenes
(PCN) - (>3 Cl atoms)
Polyvinyl chloride (PVC)/ PVC Blends
Radioactive Substances
Shortchain Chlorinated paraffins
(C10-13; Cl>=50 wt%)
Rev #: Original Rev. Date: Page 7 of 10
Y/N Max Amt Chemical name CAS #
Sodium nitrite and/or added secondary
amines, nitrosating agents or preformed
nitrosamines e.g. surfactant/preservative and
surfactant/nitrite combinations that may lead
to the formation of nitrosamines
Surface Active Agent
Triclosan
Tris (nonylphenyl) Phosphite
Volatile Organic Compounds (VOC)
Please explain “yes” answers:
Section 11 Food Contact Compliance Click here to choose
Please supply applicable reference numbers, conditions, exemptions, restrictions and/or specifications (SML)
below the table in the appropriate area. (Add lines to table as needed)
Please put an “X” in the appropriate box if the component complies with:
Japan (JHOSPA)
Compliance with
(EC) 2023/2006
EU No 10/2011
(GB9685:2008)
Measure, PIM)
South America
(MERCOSUR)
United States
Implementing
paragraphs
1935/2004
Additive?
Dual Use
(EC) No.
(Plastics
BfR- list
(GMP)
(FDA)
China
Component
1) US (FDA)
2) EU No. 10/2011 (PIM)
3) China (GB9685:2008)
4) Japan (JHOSPA)
5) South America (MERCOSUR)
Rev #: Original Rev. Date: Page 8 of 10
Raw Material Supplier Form
Appendix A
Explanation and instructions for Environmental Compliance section.
*1- CAA HAP
- Hazardous Air Pollutant, including all chemicals listed in the 1990 Clean Air Act (Note: No de minimus
level for HAPs). Please put “Y” for Yes or “N” for No.
*2- CAA VOC
-VOC as defined by 40 CFR 51.100. Please put “Y” for Yes or “N” for No.
*3- State TAP
- South Carolina Standard 8 TAP. Please put SC, if this applies.
*4- CWA
- Priority Pollutants as specified by 40 CFR 401.15. Please put “Y” for Yes or “N” for No.
*5- CERCLA RQ (lbs)
- In this column, please enter the CERCLA Reportable Quantity (RQ) or Section 304 EHS RQ for the
component, whichever is less. If the component does not have a Reportable Quantity under CERCLA or
Section 304, please enter “None” rather than leave the column blank. CERCLA RQs can be found in 40
CFR 302.4. Section 304 RQs can be found in 40 CFR 355 Subpart D. Both can be found in the EPA’s
List of Lists. (Be aware that the List of Lists is current only to 2006.)
*6- SARA 302 EHS
- SARA Extremely Hazardous Substance. Section 302. Please put “Y” for Yes or “N” for No.
*7- SARA 313
- SARA Toxic Chemical Section 313 (40 CFR 372 & amendments published in the Federal Register).
Please put “Y” for Yes or “N” for No.
CHANGE LOG
Date Rev # Initials Description of Change
Rev #: Original Rev. Date: Page 10 of 10