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PHIU CNG B SN PHM M PHM TEMPLATE FOR NOTIFICATION OF COSMETIC PRODUCT (nh du vo thch hp (Tick where applicable) THNG TIN SN PHM PARTICULARS OF PRODUCT 1. Tn nhn hng v tn Sn phm (Name of brand & product): 1.1. Nhn hng (Brand)

1.2. Tn sn phm (Product Name)

1.3. Danh sch cc dng hoc mu (List of Variants or Shade). Tn (Names) _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________ 2. Dng sn phm (Product type(s)) Kem, nh tng, sa, gel hoc du dng trn da (tay, mt, chn, .) Creams, emulsions, lotions, gels and oils for skin (hands, face, feet, etc.) Mt n (ch tr sn phm lm bong da ngun gc ho hc) Face masks (with the exception of chemical peeling products) Cc cht ph mu (lng, nho, bt) Tinted bases (liquids, pastes, powders) Cc phn trang im, phn dng sau khi tm, bt v sinh, . Make-up powders, after-bath powder, hygienic powders, etc. X phng tm, x phng kh mi,.. Toilet soaps, deodorant soaps, etc Nc hoa, nc thm dng v sinh,. Perfumes, toilet waters and eau de Cologne Cc sn phm tm hoc gi (mui, x phng, du, gel,.) Bath or shower preparations (salts, foams, oils. gels, etc.) Sn phm ty lng Depilatories Cht kh mi v chng mi. Deodorants and anti-perspirants Cc sn phm chm sc tc - Hair care products - nhum v ty tc - hair tints and bleaches - thuc un tc, dui tc, gi np tc - products for waving, straightening and fixing, - cc sn phm nh dng tc

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- setting products, -cc sn phm lm sch (sa, bt, du gi) - cleansing products (lotions, powders, shampoos), - Sn phm cung cp cht dinh dng cho tc (sa, kem, du), - conditioning products (lotions, creams, oils), - cc sn phm to kiu tc (sa, keo xt tc, sp) - hairdressing products (lotions, lacquers, brilliantines) Sn phm dng co ru (kem, x phng, sa,.) Shaving product (creams, foams, lotions, etc.) Cc sn phm trang im v ty trang dng cho mt v mt Products for making-up and removing make-up from the face and the eyes Cc sn phm dng cho mi Products intended for application to the lips Cc sn phm chm sc rng v ming Products for care of the teeth and the mouth Cc sn phm dng chm sc v t im cho mng tay, mng chn. Products for nail care and make-up Cc sn phm dng v sinh bn ngoi Products for external intimate hygiene Cc sn phm chng nng Sunbathing products Sn phm lm sm da m khng cn tm nng. Products for tanning without sun. Sn phm lm trng da Skin whitening products Sn phm chng nhn da Anti-wrinkle products Sn phm khc ( ngh ghi r) Others (please specify) 3. Mc ch s dng (Intended use) _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________ 4. Dng trnh by (Product presentation(s)) Dng n l (Single product) Mt nhm cc mu (A range of colours) Bng cc mu trong mt dng sn phm (Palette(s) in a range of one product type) Cc sn phm phi hp trong mt b sn phm (Combination products in a single kit) Cc dng khc ( ngh ghi r). Others (please specify)
1 THNG TIN V NH SN XUT/ NG GI ( ngh nh km danh sch ring nu nh c nhiu hn mt cng ty sn xut/ ng gi)

1 PARTICULARS OF MANUFACTURER (S)/ASSEMBLER(S)

(Please attach in a separate sheet if there are more than one manufacturer/assembler) 5. Tn nh sn xut (Name of manufacturer):

a ch nh sn xut (Nc sn xut) (Address of manufacturer (state country)):

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Country Tel: Fax:

6. Tn cng ty ng gi ( ngh nh du vo mc thch hp. C th nh du nhiu hn 1 (Name of assembler (Please tick accordingly. May tick more than one box)): Primary Secondary assembler ng gi chnh ng gi th cp assembler

a ch ca cng ty ng gi (Address of assembler (state country)):

Country Tel: Fax:

THNG TIN V T CHC, C NHN CHU TRCH NHIM A SN PHM M PHM RA TH TRNG PARTICULARS OF LOCAL COMPANY RESPONSIBLE FOR PLACING THE COSMETIC PRODUCT IN THE MARKET 7. Tn cng ty (Name of company):

a ch cng ty (Address of company):

Tel:

Fax:

Business Registration Number/License to Operate Number (if applicable, submit a copy of the Business Registration Certificate): S giy php kinh doanh/S giy php hot ng (nu c th, np bn sao ca giy php kinh doanh)

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THNG TIN V NGI I DIN CHO CNG TY TI A PHNG PARTICULARS OF PERSON REPRESENTING THE LOCAL COMPANY 8. H v tn (Name of person):

Tel: Chc v cng ty (Designation in the company):

Email:

Ghi ch: Nu cng ty cng b l cng ty c u quyn bi ch s hu sn phm th phi trnh th u quyn v bt k cc thng tin khc c lin quan khi c yu cu bi c quan qun l. Note: If the applicant is a service provider authorised by the company, he is required to provide a letter of authorisation or any additional particulars as required by the regulatory authority. THNG TIN V CNG TY NHP KHU PARTICULARS OF IMPORTER 9. Tn cng ty nhp khu/ Name of Importer:

a ch cng ty nhp khu/ Address of importer:

Tel:

Fax: DANH SCH THNH PHN PRODUCT INGREDIENT LIST

10. ngh kim tra sau y (Please check the following boxes) Ti kim tra bn sa i t ph lc II n ph lc VII ca danh mc cc thnh phn m phm ASEAN nh c cng b trn bn sa i gn y nht ca Hip nh m phm ASEAN. Ti xin xc nhn rng sn phm c cp n trong bn cng b ny khng cha bt c mt thnh phn b cm no v cng tun th vi danh mc hn ch v cc iu kin qui nh trong cc ph lc. I have examined the latest revisions of the Annexes II to VII of the ASEAN Cosmetic 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. Ti m nhn trch nhim tr li v hp tc ton din vi c quan c thm quyn v bt k hot ng kim sot sau khi bn hng khi c yu cu bi c quan c thm quyn. I undertake to respond to and cooperate fully with the regulatory authority with regard to any subsequent post-marketing activity initiated by the authority.

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Danh sch thnh phn y (product full ingredient list) Yu cu ghi y danh sch thnh phn v t l phn trm ca tt c cc thnh phn trong cng thc sn phm m phm - The list and percentage of all ingredients) No Tn y thnh phn (tn danh php quc t hoc s dng tn khoa hc chun c cng nhn) Full Ingredient name (use INCI or approved nomenclature in standard references) 1 2 3 4 5 6 7 8 9 10 11 12

Cam kt (DECLARATION) 1. Thay mt cho cng ty, ti xin cam kt sn phm c cp trong n cng b ny t c tt c cc yu cu trong Hng dn M phm ASEAN v cc ph lc ca n. I hereby 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. Ti xin chu trch nhim tun th cc iu khon sau y (I undertake to abide by the following conditions): i. m bo c sn cung cp cc thng tin k thut v tnh an ton khi c quan c thm quyn yu cu v c y h s v cc sn phm c phn phi bo co trong trng hp sn phm phi thu hi. Ensure that the products 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;

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ii. Phi thng bo ngay cho c quan c thm quyn v cc tc dng ph nghim trng gy cht ngi hoc e do tnh mng ca sn phm bng in thoi, fax, th in t hoc vn bn trc 7 ngy k t ngy bit thng 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. Phi hon thnh bo co tc dng ph ca sn phm (theo mu quy nh) trong vng 8 ngy lm vic k t ngy thng bo cho c quan c thm quyn v nhng tc dng ph nghim trng nh nu trong mc 2ii ni trn v cung cp bt c thng tin no theo yu cu ca c quan c thm quyn. 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; iv. Thng bo ngay cho c quan c thm quyn v cc phn ng ph nghim trng nhng khng gy cht ngi hoc e do n tnh mng ca sn phm v trong bt c trng hp no, vic bo co (s dng mu bo co) v tc dng ph phi c tin hnh trc 15 ngy k t ngy bit v tc dng dng ph ny. 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 days after first knowledge, using the Adverse Cosmetic Event Report Form; v. Cng b vi c quan c thm quyn khi c bt c s thay i no trong bn cng b ny. Notify the Authority of any change in the particulars submitted in this notification; 3. Ti xin cam oan rng nhng thng tin c a ra trong bn cng b ny l ng s tht. Tt c cc ti liu, cc thng tin lin quan n ni dung cng b s c cung cp v cc ti liu nh km l bn hp php hoc sao y bn chnh. 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. Ti hiu rng ti s c trch nhim m bo tt c cc l sn phm ca chng ti u p ng cc yu cu php lut, v tun th tt c tiu chun v ch tiu sn phm c cng b vi c quan c thm quyn. 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. 5. Ti hiu rng trong trng hp c tranh chp php lut, ti khng c quyn s dng bn cng b cht lng sn phm c c quan c thm quyn chp nhn nu phm ca chng ti khng t c cc yu cu v tiu chun, ch tiu m chng ti cng b. I understand that I cannot place reliance on the acceptance of my product notification by the authority in any legal proceedings concerning my product, in the event that my product has failed to conform to any of the standards or specifications that I had previously declared to the Authority. _______________________________________________ Tn v ch k ca ngi i din cho cng ty ti a phng [Name and Signature of person representing the local company]

______________ Du ca cng ty [Company stamp]

__________________ Ngy [Date

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