CSPA Consumer Product Ingredient Dictionary Application Form

Instructions: All suppliers or users of consumer specialty product ingredients may apply for approval of standard ingredient nomenclature to be included in the CSPA Consumer Product Ingredient Dictionary. Please complete a separate copy of this form for each ingredient, supplying all appropriate information, save each form as a Word document, and send it to CSPA at [email protected].

Ingredient Description Common Ingredient

INCI Name, if available

CAS Number

EC/List Number

Ingredients Listings REACH EPA Safer FIFRA Clean- Choice 25 (b) Gredients Chemical Formula

Ingredient Type Chemical Complex Proprietary Proprietary Compound Mixture Compound Mixture Technical/Other Names Trade Names Trade Name Mixtures

Ingredient Details Source (check all that apply) Animal Plant Mineral Synthetic Bacteria, Fungi, or Other Single Cell Organism

Definition

Chemical Class(es) Ingredient Products Containing (Describe all that apply) Functions (Check all that apply) (Describe all Aerosol Products that apply) Air Care Products Antimicrobial Products

Cleaning Products

Industrial and Automotive Chemicals Pest Management Products Polishes and Floor Maintenance Products Other

VOC Status VOC LVP Exempted VOC Partial VOC, Partial LVP Non-VOC

Comments/Other Information

Suggested Nomenclature

English

French

CSPA Consumer Product Ingredient Dictionary Application Form Spanish

Company Information Company Name Phone FAX

Address

City State Zip Code Country

Web Home Page E-mail Address

Signature Printed Name Date

For CSPA Use Only CSPA Assignment Date CSPA Assignment Number