Form - Form for Adding Third-Party Partners and Products

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Safer Choice Program
OMB Control No. 2070-0178
Form for Adding Third-Party Partners and Products
Approval expires XX/XX/XX
(Private Label Companies, Licensees, or Toll Manufacturers)
Paperwork Reduction Act Statement: The paperwork burden for this collection of information is estimated to average 16 hours per response for formulators of
cleaning and non-cleaning products and 8 hours per response for partners wishing to add third-party partners and products. Burden is defined in 5 CFR
1320.3(b). Responses to this collection of information are voluntary. 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. You may send comments regarding EPA’s need for this information, the
accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number in any correspondence. Do not send the completed application to this address.
Instructions
Type in your information. Email the form and required documents to your Safer Choice third party profiler. All third-party products must be identical to a Safer Choice
partnership product, or vary only as to minor components (reviewed by Safer Choice and specified in the Partnership Agreement). The types of third-party partners and
products are defined by their relationship to Safer Choice's direct partners (i.e., signatories to a partnership agreement):
Private Label: A Safer Choice partner places the label of another company, the private-label partner, on its Safer Choice formulation.
Licensee: A Safer Choice partner allows another company, the licensee partner, to manufacture its Safer Choice formulation and place the licensee’s label on the product.
Toll Manufacturer: A Safer Choice partner has another company, the toll-manufacturer partner, make and label its Safer Choice formulation.

STEP 1
Indicate the basic
information for the
Safer Choice partner
company here.

Partner Information
Company
Name
Website

STEP 2
If it is necessary to
update the contact
information for the
partner for either the
headquarters (HQ)
or manufacturing
(Mfg.) addresses,
please do so here.

Update Contact Information
Has your address or contact information changed since your last form submission?

Yes

No If yes, please update information

Company HQ
Address

Number of
Employees
HQ
State

HQ
ZIP

HQ
Country

Manufacturing
City

Mfg.
State

Mfg.
ZIP

Mfg.
Country

Marketing
Contact

Email

HQ City

Company Mfg.
Address

STEP 3
Indicate the contact
and relationship
information for the
third-party company
that sells the product.

Phone

Third-Party Company Information
Third Party Co.
Name
Relationship to
Safer Choice Partner

Website

Third-Party Contact Information
Third-Party Co.
HQ Address

Number of
Employees

City

State

Marketing
Contact

Email

ZIP

Country

Phone

Use this space for additional information about your relationship with the third-party company.

*Please enter product
names exactly as
they appear on your
Safer Choice
Partnership
Agreement.

Please separate UPCs
by commas.

To select a sector, first
select the sector
category in the small
drop-down of each
sector. After the
category is selected,
you may select the
specific sector from
the adjacent menu.

Please use one wide
row (marked by the
thick borders) per
product.

List up to four
different products
and indicate the
alternate names
under which they are
sold by a third-party
company, sectors,
UPC(s), production
and usage details,
and any additional
explanatory notes. If
you have additional
products, please
submit another form.

STEP 4

Brand Name:

Brand Name:

Brand Name:

Product Name:

Product Name:

Product Name:

Product Name:

Brand Name:

Brand Name:

Brand Name:

Product Name:

Product Name:

Product Name:

Product Name:

Brand Name:

Name of
third-party
company product

Brand Name:

Name of your product that is
exactly the same as the
third-party product*

GSA #:

UPC(s):

Notes:

GSA #:

UPC(s):

Notes:

GSA #:

UPC(s):

Notes:

GSA #:

UPC(s):

Notes:

Sector(s)

Safer Choice Program
Form for Adding Third-Party Partners and Products
(Private Label Companies, Licensees, or Toll Manufacturers)
If the product is
Annual
a concentrate,
production
what is the
volume
used dilution? (estimate in lbs/year)

OMB Control No. 2070-0178
Approval expires XX/XX/XX

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