Company name: Registration Number:

Address (Headquarter):

Postal Code: City:

Country:

Company Email:

Phone:Fax:

Website:

Legal representative name:

Email address:

Phone number:

Name of the person in charge of the Inputs Reviewing, if different:

Email address:

Phone number:

If the contact details you want to be listed on our website are different than the one of your Headquarter, please fill in the following blanks

Company address:

Name of the representative on the site (optional): Phone Number (optional) :

Email address (optional): Website address(optional):

Please fill out the form « My Reviewing Project – 1st Application»(below)

In order to propose you a quote matching your project, please fill the following table (all columns must be filled in). If necessary, don’t hesitate to add lines.

Please fill the second brand names in the table page 2.

Product name / Number of ingredients /product (including water) / Category / Use / Regulation
CE / NOP
Choose a category / ☐ / ☐ /
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Choose a category / ☐ / ☐ /
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Choose a category / ☐ / ☐ /
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Choose a category / ☐ / ☐ /
Choose a category / ☐ / ☐ /
Choose a category / ☐ / ☐ /
Choose a category / ☐ / ☐ /

Thank you for writing down in the table below the name of your products that have strictly the same composition but a different commercial name than the one noted above.

If you need some more lines, please feel free to add it.

Product Name
(already filled in the table above) / Other commercialName

Date, place:

Name, Position:

Signature:

ECOCERT SA | Lieudit Lamothe Ouest – BP47 – 32600 L’ISLE JOURDAIN (France) | €442,400 capital | RCS Auch 380 725002