Complete this form for each individual organic product seeking by DV8sg3Q

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									                                                                                                                                                                         Washington State Department of Agriculture
                                                                                                                                                                                              Organic Food Program
                                                                  INPUT MATERIAL FORMULATION FORM                                                                          PO Box 42560, 1111 Washington St. SE
                                                                                                                                                                                           Olympia, WA 98504-2560
                                                 REGISTRATION OF MATERIALS USED IN ORGANIC PRODUCTION AND HANDLING                                                            (360) 902-1877, organic@agr.wa.gov
                                                         For new products, changes to existing products, or 5 year review submissions                                          http://agr.wa.gov/foodanimal/organic


Registered Company Name:

Brand Name Product:
Product Manufacturer Name, City, and State:

Do alternate formulations of this material exist under the brand name listed above?                    Yes        No
If yes, submit a copy of each alternate formula and provide a full explanation regarding when the alternate formula is used.

                                                     % of Ingredient                                                                                 Indicate if the following required information
                     Ingredient                      (by weight) in         Purpose in            Name of Ingredient        Name of Ingredient              is attached to this formulation.




                                                                                                                                                                                                             Office Use
                                                        Finished            Formulation             Manufacturer           Supplier or Distributor




                                                                                                                                                      Manufacturing




                                                                                                                                                                                   Tech-Sheet or
 Give commonly accepted chemical name, trade            Product




                                                                                                                                                        Process



                                                                                                                                                                      Invoice




                                                                                                                                                                                                   MSDS
                                                                                                                                                                                       Label
  name, or Chemical Abstracts Service [CAS]                                 Active, Inert,                                  May be the same as
                  number.                            Total must add        Emulsifier, Etc.                                  the manufacturer.
                                                      up to 100%.

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                                                An electronic version of this from is available for download at: http://agr.wa.gov/foodanimal/organic
                            An EPA Confidential Statement of Formula may be substituted for pesticide products (provided all necessary attachments are also submitted).
                    Formulas are kept confidential and exempt from public inspection and copying - (RCW 15.86.110 and Uniform Trade Secrets Act, chapter 19.108 RCW.)

Declaration: I, [Print Name]                                                                                                         , an authorized representative of the company listed above, declare
that all the information provided in this formulation form is true and correct and not misrepresented in any way. I acknowledge that I am responsible for compliance with the applicable laws related to
brand name materials registration including chapter 15.86 RCW and chapter 16-160 WAC, and including, but not limited to, the obligation to notify the WSDA Organic Food Program of any changes
to the information provided in this form, to keep and provide access to records, and to provide access to facilities for inspections, sampling and audits.

Signature:

Title:                                                                                                                           Date:
AGR 2820 (N/9/11)                                                         Input Material Formulation Form – Material Registration

								
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