Raw Material Supplier Form
Section 1 General Information
Product Name:
Supplier Product No.:
Country of Origin:
Grade: (delete the irrelevant) technical, cosmetic, food, pharma, NA
Please provide Safety Data Sheet for United States and European Union.
Supplier Company Information
Name
Address
Phone
Website
ISO Certifications:
List all & provide certificates
Trade Associations: List all (global) to which you
hold a membership
Participate in
Yes/ No
Responsible Care®
or similar program?
Section 2
Contact Information
Commercial Contact
Manufacturer Company Information
Name
Address
Phone
Website
ISO Certifications:
List all & provide certificates
Trade Associations: List all (global) to which you hold
a membership
Participate in
Yes/ No
Responsible Care®
or similar program?
Technical Contact
REACH Contact
Name
Address
Phone
Email
Purchasing 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*
Regulated
Components
CAS #
Max
Wt
%
CAA
HAP
2*
3*
4*
5*
6*
A response for each section is required.
CAA
VOC
State
TAP
CWA
CERCLA
RQ (lbs)
SARA
302
EHS
7*
SARA
313
1
2
3
4
5
6
7
8
9
*see Appendix A for explanations
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
Metals Analysis
(If the number you provide is the detection limit, please mark with *. For those metals that are not
intentionally or not expected to be present, please mark with NP.)
Al
Ba
B
Cr
VI
Fe
Mg
Pb
Te
Sn
Metal
Aluminum
Barium
Boron
Sb
Be
Cd
Metal
Antimony
Beryllium
Cadmium
Chromium VI
Co
Cobalt
Iron
Magnesium
Lead
Tellurium
Tin organic
LI
Mn
Se
Tl
Zn
Lithium
Manganese
Selenium
Thallium
Zinc
Rev #: 3
Max Value
Max Value
Rev. Date: April 24, 2012
As
Bi
Cr
III
Cu
Hg
Ni
Ag
Sn
Metal
Arsenic
Bismuth
Chromium III
Max Value
Copper
Mercury
Nickel
Silver
Tin
Page 2 of 11
Section 5
General Hazard and Compliance Information:
No
Yes
Details
Is the product considered a RCRA
Hazardous Waste?
☐
characteristic/waste code(s):
Is product hazardous under the
OSHA HAZCOM standard?
Is the product a SARA 311/312
Hazard?
Is the product DOT regulated?
☐
☐
info
☐
Please delete the hazards which do not apply to this
product: acute/chronic/fire/pressure/reactive
Proper shipping name:
Is the product compliant to CONEG?
☐
☐
info
☐
info
☐
Is product EU Council Reg. EC No
2037/2000 compliant?
Is the product or any components
regulated by California Proposition
65 (Prop 65)?
Is the product classified according to
DSD (67/548/EEC), DPD
(1999/45/EC),and CLP (1272/2008)?
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 Directive 76/768/EC and
its subsequent amendments?
Does your product have any
approvals or certifications for US or
EU Pharmacopoeia?
Is this product classified under UNGHS regulations?
Is this product classified under
German Water Hazard (WGK)?
☐
☐
☐
☐
☐
☐
Substance:
info
☐
☐
If yes, please specify.
info
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
info
Please specify Monographs
☐
☐
If yes, please specify.
☐
☐
Please provide the ratings for the following categories:
Rev #: 3
Rev. Date: April 24, 2012
Page 3 of 11
Health
Flammability
Reactivity
Flashpoint:
Recommended Personal Protective Equipment:
Section 6
Toxicological Data (as available)
Data
Species
Test Method
Ingestion LD50 (mg/Kg)
Inhalation LC50 (mg/Kg)
Respiratory Sensitizer
Eye Irritation / Damage
Dermal LD50 (mg/Kg)
Skin Corrosion / Irritation
Skin Sensitizer
Fish Tox LC50 (mg/L)
Daphnia LC50 (mg/L)
Mutagenicity
Carcinogenicity
Reproductive Toxicity
Subacute/Subchronic Toxicity
Biodegradability (aerobic &
anaerobic)
Octanol Water Partition
Coefficient Kow
Additional Data
Is the product tested on animals? ☐Yes
Section 7
☐No
International Chemical Substances Approvals (include impurities or by-products)
Rev #: 3
Rev. Date: April 24, 2012
Page 4 of 11
* EC No.: _________
1) Is this product or any component subject to regulation by US EPA such as SNUR, PAIR, etc?
☐Yes
☐No If yes, please explain.
Rev #: 3
Rev. Date: April 24, 2012
Page 5 of 11
Taiwan - ECN
New Zealand –
NZIoC
China – IECSC
Philippines –
PICCS
Korea – ECL
Japan – ENCS
Australia – AICS
EU – ELINCS*
EU- EINECS*
Canada- DSL
Wt%
Canada- NDSL
CAS RN
US - TSCA
Component
Section 8
REACh Status
n
y
Pre-registered
☐
☐
Registered
☐
☐
If yes, Reg No.:
Exempted
☐
☐
Reason:
Uses Supported
☐
☐
Comments
If no, planned date:
Use Description
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
CAS No.
EC No.
Contents %
Classification, Labeling, and Packaging (CLP)
Has the material CLP classification and labeling been notified in accordance with Article 39 of
Classification, labeling, and packaging of substances of mixtures regulation 1272/2008?
☐Yes
☐No
If no, please state reason:
If yes, what is the hazard classification?
Please mark with an “X” in the appropriate box(es) below if any of the substances are classified as
carcinogenic, mutagenic, or reprotoxic in accordance with 67/548/EEC and CLP Regulation No.
1272/2008 and their subsequent amendments.
Category 1
Category 2
Category 3
Yes
Rev #: 3
Rev. Date: April 24, 2012
Page 6 of 11
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
Other- specify
Is product Kosher certified? ☐Yes
Is product Halal certified? ☐Yes
Rev #: 3
☐No
☐No
Rev. Date: April 24, 2012
Page 7 of 11
Section 10
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)
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
Natural Latex
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%)
Rev #: 3
Rev. Date: April 24, 2012
Page 8 of 11
Y/N
Max Amt
Chemical name
CAS #
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
Volatile Organic Compounds (VOC)
Please explain “yes” answers:
Section 11
Food Contact Compliance Click here to choose
Please supply applicable reference numbers, conditions, exemptions, restrictions and/or specifications below the
table in the appropriate area. Be sure to include all substances with a Specific Migration Limit (SML).
(Add lines to table as needed)
Please put an “X” in the appropriate box if the component complies with:
Compliance with
BfR- list
paragraphs
(EC) 2023/2006
(GMP)
(EC) No.
1935/2004
Dual Use
Additive?
South America
(MERCOSUR)
Japan (JHOSPA)
China
(GB9685:2008)
EU No 10/2011
(Plastics
Implementing
Measure, PIM)
United States
(FDA)
Component
1) US (FDA)
2) EU No. 10/2011 (PIM)
3) China (GB9685:2008)
4) Japan (JHOSPA)
5) South America (MERCOSUR)
Rev #: 3
Rev. Date: April 24, 2012
Page 9 of 11
Raw Material Supplier Form
Appendix A
Explanation and instructions for Environmental Compliance section.
*1- CAA HAP
- Hazardous Air Pollutant, including all chemicals listed in the 1990 Clean Air Act (Note: No de minimus
level for HAPs). Please put “Y” for Yes or “N” for No.
*2- CAA VOC
-VOC as defined by 40 CFR 51.100. Please put “Y” for Yes or “N” for No.
*3- State TAP
- South Carolina Standard 8 TAP. Please put SC, if this applies.
*4- CWA
- Priority Pollutants as specified by 40 CFR 401.15. Please put “Y” for Yes or “N” for No.
*5- CERCLA RQ (lbs)
- In this column, please enter the CERCLA Reportable Quantity (RQ) or Section 304 EHS RQ for the
component, whichever is less. If the component does not have a Reportable Quantity under CERCLA or
Section 304, please enter “None” rather than leave the column blank. CERCLA RQs can be found in 40
CFR 302.4. Section 304 RQs can be found in 40 CFR 355 Subpart D. Both can be found in the EPA’s
List of Lists. (Be aware that the List of Lists is current only to 2006.)
*6- SARA 302 EHS
- SARA Extremely Hazardous Substance. Section 302. Please put “Y” for Yes or “N” for No.
*7- SARA 313
- SARA Toxic Chemical Section 313 (40 CFR 372 & amendments published in the Federal Register).
Please put “Y” for Yes or “N” for No.
CHANGE LOG
Date
9/2/11
3/1/12
Rev #
1
2
Initials
ALR
ALR
4/24/12
3
ALR
Rev #: 3
Description of Change
logo
Added statement under SVHC for supplier pro-active communication; Added
flashpoint; added link to CONEG facts sheet; Added metals for EU; Added web
link for WEEE; Added ELV
Added ISO certs, RC participation, Trade associations; reformatted CLP CMR
Rev. Date: April 24, 2012
Page 11 of 11