The Hallstar Company PCI Raw Material & Resale Supplier Questionnaire_

PCI Supplier Raw Material and Resale Questionnaire

MANUFACTURING COMPANY
NAME  
SUPPLIER COMPANY NAME
COUNTRY
PHONE  
E-MAIL CONTACT  

*Please fill out a separate sheet for each raw material supplied.

INFORMATION ON SUBSTANCE

Name of Material Supplied:

Chemical Name, CAS#, EC#, %, INCI Composition:

% BY
CHEMICAL NAME INCI NAME CAS EC COMMENTS
WT/VOL
         
         
         
         

ORIGIN SOURCE COMMENTS

Animal    

Mineral    
 
Synthetic  

PLANT ORIGIN INFORMATION (Where Available)

 
Genus and Species
 
Wild or Cultivated Plant Source
 

Please return this Questionnaire Via EMAIL Page 1 of 8

 The Hallstar Company PCI Raw Material & Resale Supplier Questionnaire_

Country Plant Harvested

Sustainably Harvested (Yes/No)

 
Part of Plant Used

Define indexes according to the ISO 16128 part 1 and 2 (Guidelines on technical definitions and
criteria for natural and organic cosmetic ingredients and products).

PRODUCT INCI NATURAL ORGANIC ORIGIN

NATURAL INDEX ORGANIC INDEX
NAME ORIGIN INDEX INDEX

FINISHED PRODUCT COUNTRY OF ORIGIN TARIFF CODE / NCM

During growth/farm, manufacture, process or post manufacture do any of the following occur?

TOPIC YES NO Comments

Grown in sewage sludge

Pesticide use – (If YES, list pesticide residual content in finished product)

Pesticide Residues
Use of bleaching agents, additive, preservatives or antioxidants – (If YES, list
specific substance, purpose and quantity found in finished product)

Irradiated

Extracted with Solvent – (If YES, list solvent used)

Catalysts used – (If YES, note if metal-based catalyst and residual remaining)

Tested on Animals (by your company or any third party) – If NO, please attach copy of
declaration.

GMOs (Genetically Modified Organisms) or Source material/s is/are GMOs

Resulting product contains GMOs

Nanomaterials - EU Cosmetic Regulation 1223/2009/EC

Heavy Metals

Microbeads - Microbead Free Water Act 2015

Please return this Questionnaire Via EMAIL Page 2 of 8

 The Hallstar Company PCI Raw Material & Resale Supplier Questionnaire_

Does this product or manufacture site have any of the following statement?

INFORMATION YES No Comments

Certificate of Analysis (COA) of material – (Please list attach copy of certification or

statement).

Technical Specification (TDS) of material – (Please list attach copy of certification or

statement).

Safety Data Sheet (SDS) of material – (Please list attach copy of certification or
statement).

FISPQ – (Please list attach copy of certification or statement).

Manufacture Flow Chart of material – (Please list attach copy of certification or

statement).

NAFTA Certificate/Country of Origin Certificate – (Please list attach copy of

certification or statement).

Heavy Metal Analysis – (If YES please attach a list with the percentages of each
material).

Does this product or manufacture site have any of the following certifications or statement?

CERTIFICATION / STATEMENT YES NO Comments

USDA National Organic Program (NOP) – (If YES, please list attach copy of certification
or statement)

COSMOS – (If YES, please list attach copy of certification or statement)

NaTrue – (If YES, please list attach copy of certification or statement)

Sustainability Policy/Certification – If NO, list any sustainable practices that occurs:

Kosher – (If YES, please list attach copy of certification or statement)

Fair Trade Certified (If NO, list any ethical sourcing/social responsibility that occurs):
1. Marginalized and disadvantaged world producers and farmers receive sufficient
compensation for goods and services.)
2. Negotiate directly with the growers or producers of products to establish a fair price
for the products.
3. Commit to social justice in which employees and farmers are treated and paid fairly,
sustainable environmental practices are followed, and long-term trade relationships
are fostered.

Please return this Questionnaire Via EMAIL Page 3 of 8

 The Hallstar Company PCI Raw Material & Resale Supplier Questionnaire_

4. Use trading partnerships based on dialog, transparency and respect that strives for
greater justice in international trading.

Halal Certified – (If NO, answer yes or no to the below):

1. The production site does not use pork derived material as raw materials, additives
or cleaning aids and therefore can be defined as pork-free facility.
2. There are proper cleaning measures in place and appropriate measures have been
taken to segregate the final raw material from possible animal-based materials.

GMP Manufacture Site

Roundtable of Sustainable Palm Oil (RSPO) Certified – (If YES, please list attach copy
of certification or statement)

ISO 9001 Site Certified – (If YES, please list attach copy of certification or statement)

140001 Site Certified – (If YES, please list attach copy of certification or statement)

American Chemistry Council member or Responsible Care® Program

Nagoya Protocol

Other natural/organic certifications – (If YES please detail)

ACCESS AND BENEFIT SHARING REGULATIONS

YES No Comments

Is this product in compliance with Access and Benefit Sharing Regulations such as
Regulation (EU) No 511/2014, Brazilian Biodiversity law or the Nagoya Protocol?
(If NO, please explain reason).

FOOD REGULATIONS – US AND EU

Food Allergen Inquiry: Please indicate whether or not the following food allergens are used in
the manufacture of the raw material that you supply and/or are present near production
processes.
SAME
IN
POTENTIAL ALLERGEN SAME PRODUCTION PRODUCTION SAME BUILDING
PRODUCT1
LANE AREA

Celery or derivatives

Cereal /grain containing glutens or

derivatives thereof2

Crustaceans (shellfish) or derivatives3

Eggs or derivatives

Fish or derivatives4

Please return this Questionnaire Via EMAIL Page 4 of 8

 The Hallstar Company PCI Raw Material & Resale Supplier Questionnaire_

Lupin (the herb) or derivatives

Milk, dairy products or derivatives5

Molluscs or derivatives

Mustard or derivatives

Nuts or derivatives6

Peanuts or derivatives

Sesame seeds

Soy or derivatives7

Sulfur dioxide or sulfites8

NONE
1
Include information for any additives, 2Cereals containing gluten include wheat, rye, barley, oat, spelt, kamut, and their
hybrid stock, 3Includes shrimp, lobster, crab, clams, etc., 4Includes surimi, cod, pollack, whitefish, etc., 5Includes whey,
lactose, casein, milk and cream, 6Tree nuts, which include almonds, Brazil nuts, cashew nuts, chestnuts, filberts,
hazelnuts, pecans, pine nuts, pistachio nuts, Macadamia nuts, Queensland nuts and English walnuts, 7Includes soy
powder, protein, oil, lecithin, tofu, 8In excess of 10 mg/kg (10 ppm) as Sulfur Dioxide (SO2)

MANUFACTURE/ SUBSTANCE INFORMATION

Does this product contain any of the following? (Check the box and if yes, list the chemical name
and CAS#)

PRESENT IN
PRODUCT QUANTITY COMMENTS
SUBSTANCE (residual raw IN UNITS
material, impurity,
intentionally added)

Allergens – Fragrance:
Annex III of the EU Cosmetics Regulation 1223/2009/EC (CAS#)
Amyl Cinnamal (122-40-7)
Benzyl Alcohol (100-51-6)
Cinnamyl Alcohol (104-54-1)
Citral (5392-40-5)
Eugenol (97-53-0)
Hydroxycitronellal (107-75-5)
Isoeugenol (97-54-1)
Amylcin namyl alcohol (101-85-9)
Benzyl Salicylate (118-58-1)
Cinnamal (104-55-2)
Coumarin (91-64-5)
Geraniol (106-24-1)
Hydroxyisohexyl 3-cyclohexene carboxaldehyde
(31906-04-4)

Please return this Questionnaire Via EMAIL Page 5 of 8

The Hallstar Company PCI Raw Material & Resale Supplier Questionnaire_

Anise alcohol (105-13-5)

Benzyl cinnamate (103-41-3)
Farnesol (4602-84-0)
2-(4-tert-Butylbenzyl) propionaldehyde (80-54-6)
Linalool (78-70-6)
Benzyl benzoate (120-51-4)
Citronellol (106-22-9)
Hexyl cinnamal (101-86-0)
Limonene (5989-27-5)
Methyl heptin carbonate (111-12-6)
3-Methyl-4-(2,6,6-trimethyl-2-cyclohexen-1-yl)-3-butene-2-
one (127-51-5)
Oak moss extract (90028-68-5)
Treemoss extract (90028-67-4)
Animal By-products
Asbestos
California Proposition 65 Chemicals
Safe Drinking Water and Toxic Enforcement Act of 1986 - USA
Caffeine Content (for coffee products)
1,4-Dioxane
Anthraquinones (i.e., Aloin)
Bisphenol A (BPA)
BHA
BHT
Ethanol
Ethylene Glycol/Diethylene Glycol
Ethylene Oxide
Formaldehyde / Formaldehyde Donors
Fluorinated Substances
Glycol Ethers
Methanol
Nitrosamines
Parabens
Perfluorooctane Sulfonates (PFOSs)
Phthalates
Polychlorinated biphenyls (PCB)
Quaternium-15
Retinol/retinyl esters
Salicylates
Silicones (including D4/D5)
Sulfates
Titanium Dioxide
TBHQ (Tertiary Butylhydroquinone)
CITES (Convention on International Trade in Endangered Species)
CMRs (Carcinogenic, Mutagenic, Reproductive Toxins)
EC No. 1223/2009 and EC No. 1272/2008
Ozone Depleting Substances
Palm/Palm derived raw materials
If yes, are from sustainable sources (e.g. RSPO)
Residual Monomers
Solvents, residual – Class 1, Class 2, Class 3 or other residual solvents

Please return this Questionnaire Via EMAIL Page 6 of 8

 The Hallstar Company PCI Raw Material & Resale Supplier Questionnaire_

USP General Chapter <467>

SVHCs (Substances of Very High Concern)
EC No. 1907/2006
Volatile Organic Compounds (VOCs)

CONFLICT MINERALS/DODD-FRANK ACT YES No Comments

Does this product contain conflict minerals per the Dodd-Frank Act (Tin, Tantalum,
Tungsten or Gold) originating from the Democratic Republic of the Congo or an
adjoining country?

Does this product or manufacture site have any of the following statement?

TRACEABILITY
YES NO COMMENTS

Does the company have a traceability system for batch identification?

What is the estimated time capable of completely identifying the traceability of each
batch delivered to customers, in crisis situations or audits?

Briefly, describe the Traceability Program

GLOBAL COMPLIANCE

Check if the substance is listed on any of the following inventories. If exempt, please explain.
(It is not a mandatory item – Priority for Chemicals).

Please return this Questionnaire Via EMAIL Page 7 of 8

 The Hallstar Company PCI Raw Material & Resale Supplier Questionnaire_

IF EXEMPT, PLEASE
INVENTORY YES # IF DIFFERENT FROM CAS NO EXEMPT
EXPLAIN

United States TSCA

Australia AICS
Canada DSL

Canada R-ICL/ NDSL

China IECSC
China IECIC
European EINECS
Registration #
European REACH

MITI/ENCS (Japan)

MOL/ISHL (Japan)

New Zealand NZIOC

Korea KECI
Taiwan TCSI
UK REACH Registration #

Philippine PICCS
CosIng

I certify that the information in this document is accurate as of the date of completion.

Signature: Title:

Print Name: Date:

Please return this Questionnaire Via EMAIL Page 8 of 8