PHAN DANH CHO CO QUAN QI LY Phu lye sé 01-MP Neay nhan: 16/3/2020 86 céng bé: 6643/20/CBMP-HN Nguyén Van Khai PHIEU CONG BO SAN PHAM MY PHAM TEMPLATE FOR NOTIFICATION OF COSMETIC PRODUCT © Dénh dau vao 6 thich hop (Tick where applicable) THONG TIN SAN PHAM PARTICULARS OF PRODUCT 1. Tén nhan hang va tén san phim (Name of brand & product) : 1.1 Nhan hang (Brand) IG | clot p> LIT LTT 1.2 Tén sin phim (Product Name) blll] by ch] Wel bh Wh blade! Wiel I | 1.3 Danh sch cde dang ho%e mau (List of Variants or Shade). Tén (Names) 2 Dang san pham (Product type(s)) 4 San pham ding dé vé sinh co quan sinh dye ngoaiMye dich sir dung (Intended use) Ding vé sinh bé phén sinh duc ngoai, gidip: lam sach nhe nhang, khing khudn, khir mi héi, duy tri d6 am va d@ cén bing pH ty nhién cho da ving kin, bio vé ving kin, ngin ngtra vi khudn gay viém nhiém, nim ngtra, mang lai cam gic ty tin voi huong thom thom mat. Dang trinh bay (Product presentation(s)) % Dang don té (Single product) THONG TIN VE NHA SAN XUAT/ DONG GOI (Dé nghi dinh kém danh sdch riéng néu c6 nhi hon mét céng ty tham gia san xudt/ dong g6i dé tao ra mét san phd hoan chinh) ‘Tén nha san xuat (Name of manufacturer) : klolWw le] fry] fr Whale llole [D\UOlc| My Dia chi nha san xudt (Nuée sn xudt) (Address a IN UY |e IC |H|U' Jo country; wile lA reo bh bbbbkbb Tén céng ty dong g6i (dé nghi dinh déu vao myc thich hop. Co thé danh du nhigu hon 1 6 (Name of assembler (Please tick accordingly. May tick more than one box): © Dong goi chinh 1 Dong géi thir cép Primary assembler Secondary assembler loc rr ft IN|A JA (0. le G HIE kh ole] bole] My! b [bb kDja chi ctia céng ty dong g6i (Address of assembler (state country)): (rH IN|GIKM Al [Ala xX PC GIH ii |a LU IY |e | IC/H|U'JON |G} |M| IN [OI Countryk IE INA [M| reo bi ba THONG TIN VE TO CHUC, CA NHAN CHJU TRACH NHIEM DUA SAN PHAM RA THI TRUONG PARTICULARS OF LOCAL COMPANY RESPONSIBLE FOR PLACING THE COSMETIC PRODUCT IN THE MARKET ‘Tén cng ty (Name of company): ClO\N|G| |T]¥|_|T\N|nla| |r| [O|NIG AIT |OIN|G}_ [K| t/N}H Dia chi céng ty (Address of company): fo] Wha] 6 k It Iw rip) WA (OL Ie |r [A [MI kbbhbbbh| | Sé gidy phép kinh doanb/Sé gidy phép hoat dong Business Registration Number/License to Operate Number bh bhbbbp THONG TIN VE NGUOI DAI DIEN THEO PHAP LUAT CUA CONG TY PARTICULARS OF PERSON REPRESENTING THE LOCAL COMPANY Ho va tén (Name of person): fey>> = lel frebals lal [e ter hb sbbh hb DANH SACH THANH PHAN PRODUCT INGREDIENT LIST Dé nghi kiém tra 6 sau day (Please check the following boxes) @ Toi da kiém tra ban sira d6i tr Phy luc Hl dén Phy Iye VII eta danh myc ede thanh phin my pham ASEAN nhur duge céng bé trén ban sira déi gin day nhét cia Higp dinh my phim ASEAN. Toi xin xe nhan ring sin phim duge dé cép dén trong ban cong b6 nay khéng chita bat ctr mét thanh phn bj cm nao va cing tuén thi v6i danh myc han ché va céc diéu kign quy dinh trong céc phu lye. I have examined the latest revisions of the Annexes Il to VII of the ASEAN Cosm« Ingredient Listing as published in the latest amendment of the ASEAN Cosmetic Directive and confirmed that the product in this notification does not contain any prohibited substances and is in compliance with the restrictions and conditions stipulated in the Annexes. Toi dim nbn trich nhigm tra loi va hop tée toi dign véi eo quan e6 thm quyén vé bat ky hogt dng kiém sodt sau khi bén hang khi c6 yéu cdu bai co quan cé tham quyén. I undertake to respond to and cooperate fully with the regulatory authority with regard to any subsequent post-marketing activity initiated by the authority. Danh sich thinh phan day dii (product full ingredient list) (Yeu cau ghi day di dan sich han it ca cdc thinh phin va ti 1g % ciia nhimg chat 66 gidi vé ndng 46, ham lugng sit dung trong my phim - To submit ingredient list with ercentages of restricted ingredients) ‘Tén day dui thanh phan (tén danh phap quéc té hode sir dung tén sted secs khoa hoc chuan da durge céng nhin) di hen vé nding No | Full Ingredient name (use INCI or approved nomenclature in| a, him standard references) i 1_ | Purified Water 2. | Sodium Lauryl SulfateTén day dit thanh phan (tén danh phap quéc é hode sir dung tén Khoa hge chuén da dirgc cong nhén) git han vi dng Full Ingredient name (use INCI or approved nomenclature in| d, ham standard references) Zz & lugng Cellulose Gum Propylene Glycol Glycerin Piper Betle Extract (Dich Chiét Tru Khéng) Rosa Damascena Flower Extract (Dich chiét Hoa Héng) Cortex Phellodendri Extract (Dich Chiét Hoing Ba) welelalalulale Aloe Vera Extract (Djch Chiét L6 Hdi) Ss Panthenol Tocopheryl Acetate 8 Lactic Acid Menthol = PEG-40 Hydrogenated Castor Oil DMDM Hydantoin 0.6 a Fragrance Cam két (DECLARATION) - Thay mit cho c6ng ty, t6i xin cam két sin phim dge dé c@p trong Phiéu cong bé nay dat dgce tit ca cde yéu cau etia Higp dinh my phim ASEAN va cdc phy lye cia nd, Thereby declare on behalf of my company that the product in the notification meets all the requirements of the ASEAN Cosmetic Directive, its Annexes and Appendices. 2. Téi xin chiu tréch nhiém tuan thii céc diéu khoan sau day (1 undertake to abide by the following conditions): i, Dam bao c6 sin dé cung clip cde théng tin ky thuat va tinh an toan khi co quan ¢6 tham quyén yéu ciu va c6 day dit hé so vé cde sin phim da duge phan phdi dé bio c4o trong truéng hgp sin phim phai thu héi. Ensure that the product's technical and safety information is made readily available to the regulatory authority concerned (“the Authority”) and to keep records of the distribution of the products for product recall purposes;ii, Phai thdng bio ngay cho co quan cé thim quyén vé cae tic dung phy nghiém trong gay chét ngudi hoe de doa tinh mang cia sin phém bing dign thoai, fax, thu dién tir hoe van ban truée 7 ngay ké tir ngay biét théng tin, Notify the Authority of fatal or life threatening serious adverse event! as soon as possible by telephone, facsimile transmission, email or in writing, and in any case, no later than 7 calendar days after first knowledge; iii, Phai hoan thanh béo céo téc dung phy cia sin phim (theo miu quy inh) trong vong 8 ngity lim vige ké tir ngiy théng béo cho co quan e6 thim quyén vé nhing ‘ée dung phy nghiém trong nhu da néu trong muc 2ii néi ten va cung cAp bit cit théng tin nao theo yéu cau cua co quan ¢6 tham quyén. Complete the Adverse Cosmetic Event Report Form! within 8 calendar days from the date of my notification to the Authority in para 2ii. above, and to provide any other information as may be requested by the Authority; 'v. Thong béo ngay cho co quan c6 thim quyén vé cée phan ting phy nghiém trong nhung khéng gay chét ngudi ho%c de doa dén tinh mang ciia san pham va trong bat cif trudng hop nao, vige béo cdo (sit dung mau béo edo) vé téc dung phy phai duge tién hanh trude 15 ngay ké tir ngay biét vé tac dung phy nay. Report to the Authority of all other serious adverse events that are not fatal or life threatening as soon as possible, and in any case, no later than 15 calendar day's after Jirst knowledge, using the Adverse Cosmetic Event Report Form; v. Céng bé véi co quan e6 thim quyén Khi c6 bat cit sy thay i nao trong bin eéng bé nay, Notify the Authority of any change in the particulars submitted in this notification; 3. Toi xin cam doan ring nhiing thong tin duge dua ra trong ban cng bé nay la ding si that. Tat ed ede tai ligu, cde théng tin lién quan dén ndi dung c6ng bé sé durge cung cap va cée tai ligu dinh kém Li ban hgp phép hoi sao y bin chinh, I declare that the particulars given in this notification are true, all data, and information of relevance in relation to the notification have been supplied and that the documents enclosed are authentic or true copies. 4. Toi hiéu ring tdi sé c6 trach nhigm dé dim bao tit ca cde 16 sin phim cia chiing t6i déu dap img céc yéu céu phap lust, va tuan tho tét c@ tigu chudn va chi tiéu sin phim di duge céng bé véi co quan cé thm quyén. I understand that I shall be responsible for ensuring that each consignment of my product continues to meet all the legal requirements, and conforms to all the standards and specifications of the product that I have declared to the Authority. "Nhu 4 dune din nghia ring trong ti itu using de cho cic of y vi bio eto ti dung phy ca sin phim mp pm, At dejnedn the Guide Mana forthe Indus on Adverse Ever Reporingof Cosme Prodi Trinh by tong phy he I rong ti igu hung da cho ede cng ty ¥ bg edo te dung phy ea sin phém m9 phi ‘Stout im Append 10 the Gutde Manual for the Industry on Adverse Event Reporingof Cosmetics Produc5. T6i hiéu ring trong trong hgp cé tranh chap phap luét, 16i kh6ng duge quyén str dung ban céng bé sin phim my phim da duge co quan cé thm quyén chp nhan néu sin phim cia chiing tdi khéng dat duge cae yéu cdu vé tiéu chudn, chi ma ching tdi da céng bd. {understand that I cannot place reliance on the acceptance of my produet notification ay the authority in any legal proceedings concerning my product, in the event that my Tén vi chit ky ca ngudi dai dign theo phap lust cia céng ty (Name ang Signature of person representing the local company] Vuong Thanh Lam Dau cia cong ty Neay [Date] ay