F349(GL)v04.1en
ECOCERT Greenlife
01/08/2013
Questionnaire for the non organic raw material verification
according to the Ecocert natural and organic cosmetic
standard
This questionnaire must be completed and signed by the manufacturer of the raw material;
Information given is under his own responsibility.
TDS and MSDS must be joined to this questionnaire.
COMMERCIAL NAME:
I – GENERAL INFORMATION about your company and your product:
1. Manufacturer:
Name of the company:
Address:
Phone:
Fax:
Email:
2. Supplier/Distributor, if different:
Name of the company:
Address:
Phone:
Fax:
Email:
3. Category/Function:
4. Chemical formula:
5. CAS number:
6. INCI name:
II – INGREDIENTS AND REACTANTS:
1. Origin and manufacturing processes:
Please list exhaustively in the table below each ingredient (active ingredient or solvent)
of the commercial reference mentioning:
- its name
- its origin (plant/marine, mineral, animal, synthetic)
- its manufacturing process*
- the reactants used, their origin (plant/marine, mineral, animal, synthetic) and their
manufacturing process*
- the content (%) in the commercial reference
*In case of ingredients or reactants coming from biotechnological process, please precise the
substrate and the culture medium composition.
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F349(GL)v04.1en
Name of the
ingredient
ECOCERT Greenlife
Origin
01/08/2013
Reactants (origin and
manufacturing process)
Manufacturing process
%
Example:
Glyceryl
stearate
Plant
Esterification of glycerol and
stearic acid
Glycerol (Saponification of a
vegetable oil)
Stearic acid (Saponification,
neutralisation and distillation
without solvent of a vegetable
oil)
Example:
Lemon
essential oil
Plant
Hydrodistillation
Lemon zest (plant, grinding)
5
Example:
sorbic acid
Synthetic
X
2
X
A. Auxiliaries:


Definition: Component intentionally used in necessary and sufficiency quantity to allow,
facilitate and optimize a step of the manufacturing process of an ingredient but that you
don’t find in the final ingredient
Example: catalyst
Are manufacturing auxiliaries used during the
synthesis of the ingredients listed previously?
Are the manufacturing auxiliaries removed in a
purification step?
Are the manufacturing auxiliaries detectable by
analysis?
YES
NO
If yes, which ones:
YES
NO
YES
NO
If YES, precise the component(s) and
content(s):
B. Plant ingredients (physically transformed):
Is a petrochemical solvant used for the
manufacturing of these ingredients?
YES
NO
If yes, which one:
For an aqueous extract, what is the result of the ratio: quantity of dry plant used / quantity of
final extract obtained after filtration?:
As a reminder: dry plant = fresh plant / 4
This document is property of ECOCERT.
Any reproduction whether in whole or in part of this document, without written consent from ECOCERT is illegal.
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F349(GL)v04.1en
ECOCERT Greenlife
01/08/2013
C. Mineral ingredients (physically transformed) and ingredients from
mineral origin (chemically transformed):
Are these ingredients considered as
« nanomaterials » according to the definition of the
Regulation (EC) n° 1223/2009 on cosmetic
products?
YES
NO
If yes, which ones:
D. Animal ingredients and ingredients from animal origin:
Are some ingredients used for the manufacturing of
the commercial reference part of the animal?
Example: enzyme
YES
NO
If yes, which ones:
If an ingredient from animal origin is used, has it
caused the stress, the pain or the death of the
animal?
YES
NO
If yes, which one:
2. Additional questions:
A. Forbidden processes ans components:
Can you confirm that the forbidden processes below are not used during the manufacturing
process of the ingredients contained in the commercial reference, the obtention of the
reactants or the manufacturing process of the auxiliaries?
YES
NO
Bleaching on an animal support
Deodorisation on an animal support
Irradiation (ionizing rays: alpha, gamma)
Sulphonation (except for the auxiliaries)
Treatment using mercury (mercurial soda or
potash)
Use of ethylene oxide
Use of formaldehyde
Quaternisation of amines
If NO, precise the ingredient(s) concerned and the reaction(s) involved:
Do you use the following components among your reactants: MEA, DEA, TEA?
YES
NO
B. Derived GMO:
Are the plants used in the manufacturing process of your
commercial reference, as ingredient, reactant or solvent,
guaranteed GMO-free?
YES
NO
For biotechnological process:
Are all raw materials of the biotechnological process
PCR(-)?
YES
NO
This document is property of ECOCERT.
Any reproduction whether in whole or in part of this document, without written consent from ECOCERT is illegal.
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F349(GL)v04.1en
ECOCERT Greenlife
01/08/2013
3. Additives:
Are additives added to the commercial reference?:
YES
NO
If YES, precise which ones, their name, origin, manufacturing process and content (%):
Preservatives:
Antioxidants:
Other additives :
4. Secondary components and impurities:
Indicate for each of the following constituents whether it enters the commercial reference (as
a component or by-product) and if there is no data, please indicate « ? »:
YES
(content in ppm)
NO
?
1.4-Dioxane
Ethylene oxyde
Propylene oxyde
Free amines:
Amidoamine (>0,5%):
Monoethanolamine (>0,5%)
Heavy metals (cadmium, mercury, antimony,
arsenic, chromium, cobalt, nickel, lead, silver)
concentration > 10 ppm :
Pesticides (-, -, -HCH, DDT, DDE,
dichlofenthion, PCBs) 
Aromatic hydrocarbon
Other residues or impurities (names, origins, manufacturing processes and contents (%)):
I undersigned,
, representing the company,
this questionnaire is correct.
Issued in
, on
, declare that the information given in
.
Signature compulsory (with the sentence « read and approved »)
This document is property of ECOCERT.
Any reproduction whether in whole or in part of this document, without written consent from ECOCERT is illegal.
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