Department of Health and Human Services Form 2512a

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                                                                                      Form Approved: OMB N0. 0910-0030.    Expiration Date: December 31, 2008
               DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                     See Burden Statement on Reverse of Part I.
                    FOOD AND DRUG ADMINISTRATION
                      COLLEGE PARK, MD 20740-3835                                                                                                        AMENDED
                                                                                      TYPE OF SUBMISSION:                     ORIGINAL

   COSMETIC PRODUCT INGREDIENT STATEMENT                                                       FOR FDA USE ONLY ON ORIGINAL SUBMISSIONS
                          (In accordance with 21 CFR 720)
                                                                                       FDA CPIS NO.                               FILING DATE
  Read Instruction Booklet Before Completing. Type entries in CAPITAL LETTERS.
                                                                                       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


                2. 9 - DIGIT CAS NO.                    3. TYPE OF ACTION                      4. DATE OF ACTION                      5. CONF

 01             6. BASE CPIS NO.           7. BASE NAME OR TRADE NAME MATERIAL                                  8. COMPANY NAME
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                1. COMMON, USUAL, OR CHEMICAL NAME


                2. 9 - DIGIT CAS NO.                    3. TYPE OF ACTION                      4. DATE OF ACTION                      5. CONF
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                6. BASE CPIS NO.           7. BASE NAME OR TRADE NAME MATERIAL                                  8. COMPANY NAME
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                2. 9 - DIGIT CAS NO.                    3. TYPE OF ACTION                      4. DATE OF ACTION                      5. CONF
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                6. BASE CPIS NO.           7. BASE NAME OR TRADE NAME MATERIAL                                  8. COMPANY NAME
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                1. COMMON, USUAL, OR CHEMICAL NAME


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                6. BASE CPIS NO.           7. BASE NAME OR TRADE NAME MATERIAL                                  8. COMPANY NAME
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                1. COMMON, USUAL, OR CHEMICAL NAME


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                6. BASE CPIS NO.           7. BASE NAME OR TRADE NAME MATERIAL                                  8. COMPANY NAME
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                1. COMMON, USUAL, OR CHEMICAL NAME


                2. 9 - DIGIT CAS NO.                    3. TYPE OF ACTION                      4. DATE OF ACTION                      5. CONF
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                6. BASE CPIS NO.           7. BASE NAME OR TRADE NAME MATERIAL                                  8. COMPANY NAME
                F                      B
                1. COMMON, USUAL, OR CHEMICAL NAME


                2. 9 - DIGIT CAS NO.                    3. TYPE OF ACTION                      4. DATE OF ACTION                      5. CONF
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                6. BASE CPIS NO.           7. BASE NAME OR TRADE NAME MATERIAL                                  8. COMPANY NAME
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                6. BASE CPIS NO.           7. BASE NAME OR TRADE NAME MATERIAL                                  8. COMPANY NAME
                F                      B
FORM FDA 2512a (6/06)        Previous Edition is Obsolete.      This Form Must be Securely Attached to Form FDA 2512.                             PSC Graphics: (301) 443-1090   EF

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    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:

    DHHS/FDA/CFSAN                                                       An agency may not conduct or sponsor, and a person is not required to respond to, a
    Office of Cosmetics and Colors                                       collection of information unless it displays a currently valid OMB control number.
    Voluntary Cosmetic Registration Program (HFS-125)
    5100 Paint Branch Parkway
    College Park, MD 20740-3835




FORM FDA 2512a (6/06) (BACK)

				
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Description: Department of Health and Human Services Form