Form Fda 2512 Cosmetic Product Ingredient Statement

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Expiration Date: August 31, 2017.

Form Approved: OMB N0. 0910-0027.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

See Burden Statement on Reverse of Part

FOOD AND DRUG ADMINISTRATION

COLLEGE PARK, MD 20740-3835

TYPE OF SUBMISSION:

ORIGINAL

AMENDED

DISC

BASE

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.

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.

01. NAME OF MANUFACTURER / PACKER / DISTRIBUTOR (On Label)

11. NAME OF MANUFACTURER / PACKER (Private Labeler)

02. KIND OF BUSINESS

PKR

DISTR

MFR

03. NAME OF PARENT COMPANY (If any)

12. NAME OF PARENT COMPANY (If any)

04. COMPLETE MAILING ADDRESS:

13. COMPLETE MAILING ADDRESS:

14. IS THIS STATEMENT FILED BY COMPANY 01 OR COMPANY 11?