Form FDA2512 Cosmetic Product Ingredient Statement

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Form Approved: OMB N0. 0910-0030.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
COLLEGE PARK, MD 20740-3835

TYPE OF SUBMISSION:

COSMETIC PRODUCT INGREDIENT STATEMENT

ORIGINAL

Expiration Date: December 31, 2008.
See Burden Statement on Reverse of Part I.
AMENDED

Read Instruction Booklet Before Completing. Type entries in CAPITAL LETTERS.

BASE

FOR FDA USE ONLY ON ORIGINAL SUBMISSIONS
FDA CPIS NO.

(In accordance with 21 CFR 720)

DISC

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

02. KIND OF BUSINESS

MFR

PKR

11. NAME OF MANUFACTURER / PACKER (Private Labeler)

DISTR

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?
(Please check one)
COMPANY 01
COMPANY 11

15. PRODUCT CATEGORY CODE:

BRAND NO.

16. BRAND NAME OF COSMETIC PRODUCT

17. TYPE OF ACTION

18. DATE OF ACTION

01

02

03

04

05

06

07

08
19. TYPE NAME AND TITLE OF AUTHORIZED INDIVIDUAL

20. TELEPHONE NO.

(

21. SIGNATURE AND DATE

)

FORM FDA 2512 (6/06) CONTINUE COSMETIC PRODUCT INGREDIENT STATEMENT ON FORM FDA 2512a
EF PSC Graphics: (301) 443-1090

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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
Office of Cosmetics and Colors
Voluntary Cosmetic Registration Program (HFS-125)
5100 Paint Branch Parkway
College Park, MD 20740-3835

FORM FDA 2512 (6/06) (BACK)

An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number.

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FOR FDA USE ONLY

OFFICIAL RECEIPT
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
COLLEGE PARK, MD 20740-3835
BRAND NAME OF COSMETIC PRODUCT

1.

2.

COSMETIC PRODUCT INGREDIENT STATEMENT
TO:

1
FDA CPIS NO. F

FILING DATE
THIS STATEMENT IS
COMPLETE

INCOMPLETE

(If Incomplete, Form FDA 2515 is attached)
1

Assignment of an FDA Cosmetic Product Ingredient Statement Number (FDA CPIS No.) does not denote in any way approval of the firm or the cosmetic product by the Food and
Drug Administration. Any representation in labeling or advertising that creates an impression of official approval because of such filing or such number will be considered
misleading. 21 CFR 720.9

FORM FDA 2512 (6/06)