2512 Cosmetic Product Ingredient Statement

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

Expiration Date: February 29, 2012.
See Burden Statement on Reverse of Part I.

ORIGINAL

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

DISC

BASE

FOR FDA USE ONLY ON ORIGINAL SUBMISSIONS
FDA CPIS NO.

(In accordance with 21 CFR 720)

AMENDED

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.

FORM FDA 2512 (6/09) CONTINUE COSMETIC PRODUCT INGREDIENT STATEMENT ON FORM FDA 2512a
EF

PSC Graphics: (301) 443-1090

21. SIGNATURE AND DATE

Page

of

Pages

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FORM FDA 2512 (6/09) (BACK)

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collection of information unless it displays a currently valid OMB control number.

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:

FDA CPIS NO.1

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 (6/09)