Raw Material Supplier Form
Section 1
General Information
Product Name:
Supplier Product No.:
Country of Origin/Manufacturing:
Grade: (delete the irrelevant) technical, cosmetic, food, pharma, NA
Location:
Please provide Safety Data Sheet for United States and European Union.
Supplier Company Information
Name
Address
Phone
Website
ISO Certifications
(List all):
Trade Associations:
List all (global) to
which you hold a
membership
Participate in
Yes/ No
Responsible Care®
or similar program?
Contact Information
Commercial Contact
Name
Address
Phone
Email
Manufacturer Company Information
Name
Address
Phone
Website
ISO Certifications
(List all):
Trade Associations:
List all (global) to
which you hold a
membership
Participate in
Yes/ No
Responsible Care®
or similar program?
Section 2
Purchasing Contact
Technical Contact
REACH Contact
Regulatory Contact
Name
Address
Phone
Email
The below signature certifies that all the information supplied in this form is current, complete, and accurate. The
supplier understands that Milliken & Company is relying on Supplier’s certification to ensure Milliken & Company’s
compliance with applicable global legal requirements and regulations.
Name:
Phone:
Email:
Signature:
Date:
Section 3
Environmental Compliance
1*
Components
CAS #
Max
Wt
%
2*
3*
4*
5*
6*
A response for each section is required.
CAA
HAP
CAA
VOC
State
TAP
CWA
CERCLA
RQ (lbs)
SARA
302
EHS
7*
SARA
313
1
2
3
4
5
6
*see http://www.supplier.milliken.com/en-us/Pages/ehsreqs.aspx for definitions and lists.
Answer at least one of the below questions with regards to Volatile Organic Compounds (VOCs):
1) Total VOC’s by EPA method 24/24A (%):__________________
2) Total VOC’s estimated based on product composition (%): ______________________
Section 4
1)
2)
3)
4)
Metals Analysis
Be sure to provide correct units for values.
Detection limit – mark value with *.
Not present – mark with NP for those metals that are not intentionally added or not expected to be present.
Please provide data on hand. No new testing is required at this time.
Al
Ba
B
Cr VI
Fe
Mg
Pb
Te
Sn
Au
Rev #: 9
Metal
Aluminum
Barium
Boron
Chromium VI
Iron
Magnesium
Lead
Tellurium
Tin organic
Gold
Max Value
Sb
Be
Cd
Co
LI
Mn
Se
Tl
Zn
Ta
Metal
Antimony
Beryllium
Cadmium
Cobalt
Lithium
Manganese
Selenium
Thallium
Zinc
Tantalum
Max Value
Rev. Date: May 29, 2015
As
Bi
Cr III
Cu
Hg
Ni
Ag
Sn
W
Sr
Metal
Arsenic
Bismuth
Chromium III
Copper
Mercury
Nickel
Silver
Tin
Tungsten
Strontium
Max Value
Page 2 of 8
Section 5
General Hazard and Compliance Information:
United States Regulations
Is product classified under the OSHA
HAZCOM 2012 standard and/or
UNGHS?
Is the product a SARA 311/312
Hazard?
Is the product regulated for transport
under USDOT, IATA and/or IMDG
regulations?
Is the product considered a RCRA
Hazardous Waste?
Is the product or any components
regulated by California Proposition 65
(Prop 65)?
Is the product compliant to CONEG?
Yes
☐
☐
☐
☐
info
☐
info
Please delete the hazards which do not apply to this
product: acute/chronic/fire/pressure/reactive
Proper shipping name:
☐
☐
Listed/characteristic waste code(s):
☐
☐
Substance:
☐
Details
info
European Regulations
Is the product classified according to
DSD (67/548/EEC), DPD
(1999/45/EC),and CLP (1272/2008)?
Is this product classified under German
Water Hazard (WGK)?
Is product EU Council Reg. EC No
1005/2009 compliant for ozone
depletors?
Is the product compliant to Directive
2011/65/EU on the restriction of the
use of certain hazardous substances in
electrical and electronic equipment
(RoHS) and is the product compliant to
Directive 2002/96/EC on waste
electrical and electronic equipment
(WEEE)?
Is the product compliant to Directive
94/62/EC on packaging and packaging
waste?
Is the product compliant to Directive
2000/53/EC on end-of life vehicles?
Is the product compliant to Safety of
Toys EN 71 part 3 and part 9?
Is the product compliant to the
Cosmetics Regulation 1223/2009/EC
and its subsequent amendments?
Does the product have any approvals
or certifications for US or EU
Pharmacopoeia?
Rev #: 9
No
☐
☐
☐
☐
If yes, please specify.
info
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
info
If yes, please specify the WGK class.
Please specify Monographs
Rev. Date: May 29, 2015
Page 3 of 8
Section 6
International Chemical Substances Approvals (include impurities or by-products)
Is this product or any component subject to regulation by US EPA such as SNUR, PAIR, etc?
☐Yes
☐No If yes, please explain.
Section 7
REACh Status
Chemical name and CAS#
Pre-registered (y/n)
Registered (y/n)
Number if registered
Exempted (reason)
Uses supported
(*descriptor codes)
Brief description of
use
*Use descriptor codes: Sector of use (SU) , Process category (PROC), Product Category (PC), Environmental
Release Category (ERC), Specific Environmental Release Category (SPERC)
 http://echa.europa.eu/documents/10162/13632/information_requirements_r12_en.pdf
Rev #: 9
Rev. Date: May 29, 2015
Page 4 of 8
Taiwan - ECN
New Zealand –
NZIoC
China – IECSC
Philippines –
PICCS
Korea – ECL
Japan – ENCS
Australia – AICS
Switzerland ChemO
SR 813.11
Wt%
EU
Canada- DSL
CAS RN
Canada- NDSL
US - TSCA
Component
1
2
3
4
5
6
Substances of Very High Concern (SVHC)
reference link: Candidate List
☐ Our product defined above does not contain any of the chemicals listed in the Candidate List (last update prior to
completion date of this form) of Substances of Very High Concern for Authorization stated in the REACH Regulation
(1907/2006/EC), in a concentration above 0.1%.
☐ As revisions are made to the Candidate List which effect a change in the status of the subject product supplied to
Milliken & Company by our company, we will communicate the change in status within 30 days.
Please complete the table below for any components that are on the List of Substances of Very High Concern for
Authorization, last update prior to completion date of this form. Add lines as needed.
Name of Substance
Section 8
CAS No.
EC No.
Contents %
Toxicological Data (as available)
Data
Species
Test Method
Ingestion LD50 (mg/Kg)
Inhalation LC50 (mg/Kg)
Eye Irritation / Damage
Dermal LD50 (mg/Kg)
Skin Corrosion / Irritation
Aquatic Toxicty
Mutagenicity
Carcinogenicity
Reproductive Toxicity
Biodegradability (aerobic &
anaerobic)
Additional Data
Is the product tested on animals? ☐Yes
Rev #: 9
☐No
Rev. Date: May 29, 2015
Page 5 of 8
Section 9
Product Origin and Allergens
Does this product contain or is derived from any of the below?
Y/N
Substance
Max
Amt
CAS #
Genetically Modified
Organisms
Synthetic origin?
Mineral origin? Specify
Animal Origin? Specify
Contains BSE/TSE?
Plant Origin? Specify
Allergens:
Peanuts
Soy Beans
Milk
Eggs
Fish
Crustaceans
Tree Nuts
Wheat
Cereals w/gluten
Celery
Sesame Seed
Natural Latex
Other- specify
Is product Kosher certified? ☐Yes
Is product Halal certified? ☐Yes
Section 10
☐No
☐No
Substances of Concern
Does your product contain any of these substances of concern? Please explain any “yes” answers below the table.
Y/N
Max Amt
Chemical name
CAS #
Algaecide/Biocide
Alkyl phenols (straight chain) and their
ethoxylates
Aromatic amines
Aromatic hydrocarbons
Asbestos
Azo colorants/compounds
Bisphenol A
Brominated flame retardants (other than
PBB/PBDE)
Butylated Hydroxytoluene (BHT)
Canadian Challenge Substances
Defoamers
Diaryl Pigments
1,4-Dioxane
Dioxins/Furans (e.g. brominated/chlorinated)
Rev #: 9
Rev. Date: May 29, 2015
Page 6 of 8
Y/N
Max Amt
Chemical name
CAS #
Epoxy derivatives (e.g. BADGE, BFDGE,
NOGE)
Ethylene Oxide
Fluorochemicals
Formaldehyde or potential formaldehyde
releasers/donors
Halogens and their compounds
(e.g. brominated/chlorinated)
Mono- and Diethylene series glycol ethers
Naphthalene
Nonyl phenol and nonyl phenol ethoxylates
Organotin Compounds
(Tributyl tin or Triphenyl tin compounds)
Ortho Phenyl Phenol
Ozone Depleting Substances, Class I
Ozone Depleting Substances, Class II
Paradiclhorbenzene (PDCB)
Perfluorooctanoic Acid (PFOA)
Phthalates
Polybrominated biphenyls (PBB)
Poly brominated diphenyl ethers/oxides
(PBDE/PBDO)
Polybrominated Flame Retardants (PBFR)
Polychlorinated biphenyls (PCB)
Polychlorinated terphenyls (PCT)
Polychlorinated naphthalenes
(PCN) - (>3 Cl atoms)
Polyvinyl chloride (PVC)/ PVC Blends
Radioactive Substances
Shortchain Chlorinated paraffins
(C10-13; Cl>=50 wt%)
Sodium nitrite and/or added secondary
amines, nitrosating agents or preformed
nitrosamines e.g. surfactant/preservative and
surfactant/nitrite combinations that may lead
to the formation of nitrosamines
Surface Active Agent
Triclosan
Tris (nonylphenyl) Phosphite
Please explain “yes” answers:
Rev #: 9
Rev. Date: May 29, 2015
Page 7 of 8
Section 11
Food Contact Compliance
in component section below.)
(If product is NOT food contact compliant, mark Not Applicable
Please supply applicable reference numbers, conditions, exemptions, restrictions and/or specifications below the
table in the appropriate area. Please be sure to include all substances with a Specific Migration Limit (SML),
Dual use Additives and Nanoform Substances.
(Add lines to table as needed)
4
5
6
Section 12
Biocidal Product(s) Compliance
(If product is NOT a biocide, mark Not Applicable)
Response
1
Please specify the biocidal active substance(s) contained
in the biocidal product (name, CAS#, concentration)
2
Is the biocidal active substance(s) being supported by
your company under the Biocidal Products Regulation
(EU) 528/2012? Please specify Product Types.
3
Is your company included in the ‘Article 95’ list as an
authorised EU supplier of the appropriate biocidal active
substance(s)
4
Has the biocidal active substance(s) been approved for
your company under the Biocidal Products Regulation
(EU) 528/2012? Please specify Product types & provide
the Commission Implementing Regulation reference(s).
5
Do you hold any National Approvals for your biocidal
product? Please specify the Member State(s) and Product
Type(s).
6
For each biocidal active substance, please confirm
compliance with the following and list any restrictions: Directive 2009/48/EC of the European Parliament
and of the Council of 18 June 2009 on the safety
of toys
 EN71 Safety of Toys Standards
Rev #: 9
Rev. Date: May 29, 2015
Page 8 of 8
Switzerland
South America
(MERCOSUR)
Japan (JHOSPA)
China
(GB9685:2008)
EU 10/2011 Dual
Use Additive?
EU No. 10/2011
(PIM, Dual Use
Additive)
EC 2023/2006
(GMP)
Framework Regs
(EC) No.
1935/2004
United States
(FDA)
Component
1
2
3