CONFIDENTIAL

Raw Material Information Form (RMIF)

Vendor Name:
Product Name:
JDE item number**:

**To be completed by Expera’s Purchasing Department.

Expera requires suppliers to provide the following information requested on this form to enable us to ensure that Expera products containing your material will comply with global regulatory requirements.

This document is required in addition to the Material Safety Data Sheet (MSDS)

If there are any changes to your material or to the manufacturing processes that may affect the material in the future, we require that you re-submit this document with the appropriately updated MSDS to the Expera Purchasing Department. This includes changes in manufacturers of a product. A separate RMIF form should be completed for each manufacturer.

1. General Information

Vendor Name:

Vendor Address:

Prepared by:

Position:

Email:

Phone:

Signature:

Please provide the contact information for the person in your company that handles Regulatory or Health/Safety inquiries if different from above.

Name:

Position:

Email:

Phone:

2. Product Information

Product Trade Name:

Is your company the manufacturer of this product? Yes No

If not, please provide the name of the manufacturer?

Is the manufacturer of this product ISO certified? Yes No

Is the manufacturer of this product certified under GMP, ASI or equivalent? Yes No

3. Chemical Composition

Please complete the table below listing the chemical names and CAS numbers for all of the components in your finished product. In the comment section please indicate whether this is an active ingredient, residual by-product, or impurity. The information you provide is confidential and will not be share with any of our customers unless agreed between Expera and your company.

CAS number / Chemical Name / Comments
4. Origin of Manufacture and Chemical Control Laws

Where is this material manufactured – specify country?

Is the finished product (all components) listed on the country specific chemical inventories in the table below? US-TSCA and Canada DSL/NDSL are priorities in this list and should not be left blank.

Inventory / Yes / No / Exempt / Comments
USA (TSCA)
Canada (DSL)
Canada (NDSL)
Europe (EINECS)
Europe (ELINCS)
China (IECSC)
Japan (METI/CSCL)
Japan (MHLW/ISHL)
Korea (KECI)
Philippines (PICCS)

More information on the USA-TSCA inventory located at:

http://www.epa.gov/oppt/existingchemicals/pubs/tscainventory/howto.html

More information on Canada DSL and NDSL inventory located at:

http://www.ec.gc.ca/lcpe-cepa/default.asp?lang=En&n=5F213FA8-1&wsdoc=D031CB30-B31B-D54C-0E46-37E32D526A1F

http://ec.gc.ca/lcpe-cepa/default.asp?lang=En&n=8BD37498-1

5. Regulatory Requirements

5.1 Is this product or its components FDA approved?

Yes No

If yes, please attach a copy of your FDA declaration/certificate or list below all the applicable sections and restrictions that apply to your product. We do not accept a positive answer without the specific sections/restrictions that apply to your product under FDA Title 21 CFR.

5.2 Is this product Kosher Certified?

Yes No

If yes, please attach a copy of the Kosher Certificate.

If no, provide “positive letter of derivation” to our Kosher Certification Company per the instructions in the separate attached letter.

5.3 Does this product contain substances listed under Safe Drinking Water and Toxic Enforcement Act of 1986 (Proposition 65)? Current list is located at:

http://www.oehha.ca.gov/prop65/prop65_list/Newlist.html

Yes No

If yes, please specify chemical name, CAS number and concentration (% or ppm) in your product:

5.4 Does this product contain substances listed under the Canadian Enviromental Act (CEPA Challenge), Batches 1 through 12?

Yes No

If yes, please specify chemical name, CAS number and concentration (% or ppm) in your product:

5.5 Does this product contain Substances of Very High Concern listed under REACH? Current list located at: http://echa.europa.eu/candidate-list-table

Yes No

If yes, please specify chemical name, CAS number and concentration (% or ppm) in your product:

5.6 Do you have a CFIA (Canadian Food Inspection Agency) file number for this product?

Yes No

If yes, please provide CFIA number:

5.7 Is this material considered hazardous by Canadian WHMIS?

Yes No

5.8 Does your material contain conflict minerals as listed in section 1502 of the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010 (Dodd-Frank Act)?

Yes No

If yes, please specify:

6. Chemicals of Concern

Please indicate if your material contains any of the following and the amount contained in weight % or ppm

CAS Number / % or ppm / Comments: Please supply chemical name
Metals & Metal Compounds / Yes No
Antimony/Antimony Compounds / Yes No
Arsenic/Arsenic Compounds / Yes No
Beryllium/Beryllium Compounds / Yes No
Bismuth/Bismuth Compounds / Yes No
Cadmium and Cadmium Compounds / Yes No
Hexavalent Chromium (Cr VI) Compounds / Yes No
Copper/Copper Compounds / Yes No
Lead and Lead Compounds / Yes No
Mercury and Mercury Compounds / Yes No
Nickel/Nickel Compounds / Yes No
Selenium/Selenium Compounds / Yes No
Silver/Silver Compounds / Yes No
Zinc/Zinc Compounds / Yes No
Other Chemicals
Asbestos / Yes No
Azo colorants / Yes No
Bisphenol A & Bisphenol A compounds / Yes No
Brominated flame retardants (PBB’s or PBDE’s) / Yes No
Alkylphenol/ Alkylphenolethoxylates (AP/APE)? / Yes No
Nonyl Phenol Ethoxylate (NPE) / Yes No
Formaldehyde / Yes No
Halogenated Compounds (Specify which)
Bromine____ Chlorine_____
Fluorine______Iodine_____ / Yes No
Materials of human or animal origin / Yes No
Genetically Modified Materials (GMOs) / Yes No
Melamine / Yes No
Ozone Depleting Substances / Yes No
PFOS / PFOA / Yes No
Phthalates / Yes
Polyaromatic Hydrocarbons (PAHs) / Yes No
Natural Rubber or Natural Rubber Latex / Yes No
Crystalline Silica / Yes No
Silicone / Yes No
Vinyl Chloride Polymer (PVC) / Yes No
Triclosan (2,4,4’-trichloro-2’-hydroxydiphenyl ether) / Yes No
Volatile Organic Carbon (VOC) Compounds – List individual components and weight % / Yes No

Does this product contain any substances regulated as a state and/or federal hazardous or conventional air pollutant? (Above the threshold amounts of 0.1% for known or potential carcinogens and 1% for non carcinogens listed on NR445 Table A, Wisconsin Administrative Code and/or the Clean Air Act hazardous air pollutant list).

Yes No

If yes, indicate substance(s) and concentration -

7. Allergens

Please indicate if your material contains any of the following and the amount contained in the material in weight % or ppm, ppb as appropriate.

Question / CAS # / % Weight / Or
ppm / Comments: Please supply chemical name and detection limits where possible?
Fish and Fish Products - (Cod , Pollock,whitefish, tuna, herring, sardines and any other derivitive of fish and their products ( fish protein, surimi, fish paste, caesar dressing, cheese sauce, worcestershire sauce, Caesar dressing. / Yes No
Milk and Milk Products – (cow's milk, butter, butterfat, buttermilk, casein, cream, sodium caseinate, curds, whey, cheese, yogurts, lactose, lactoglobulin, sour cream, or any derivative of milk or milk products, etc..) / Yes No
Crustacean/Shellfish and Crustacean/Shellfish Products ( shrimp, prawns, crab, lobster, crawfish, oysters, clams, scallops, mussels, abalone, cockles, snails, squid, octopus, or any crustacean or shellfish derivative, etc..) / Yes No
Soybean and Soybean Products – (soy, miso, hydrolyzed soy protein, texturized soy protein, soy sauce, tofu, bean curd, soy flour,etc..) / Yes No
Wheat and Wheat Products - ( wheat, wheat bran, cereal extracts, bulgur, farina, wheat germ, graham flour, malt, gluten, spelt, kamut, triticale , wheat starch, wheat flour, semolina, cracker meal, durum flour, bread crumbs, high protein flour, etc..) / Yes No
Sesame Seed and Sesame Seed Products – (sesame seeds, sesame seed flour, cold pressed sesame seed oil, etc....) / Yes No
Buckwheat (Fagopyrum) buckwheat, buckwheat flour, cereal extracts, or any buckwheat or buckwheat derivative, etc. / Yes No
Gluten – and related proteins obtained from wheat, rye, barley and oats spelt and ingredients derived from these cereal grains and their hybridized strains. / Yes No
Celery – Celery or celery derivatives, etc. / Yes No
Sulfur Dioxide & Sulfites at any concentrations. / Yes No
Pulp Suppliers only
Sustainable Forestry (Pulp Suppliers Only)
Are you FSC/SFI/PEFC COC certified? List type of certification and certificate number, and attach copy of your certificate. For non-certified sources, a controlled wood risk assessment must be included.
Dioxins and furans (Pulp Suppliers only)
The results reported should be based on EPA method 1613B or equivalent
Please state the TDE (total dioxin equivalent) and date of result.
Chlorine (Pulp Suppliers only)
Is your product ECF (Elemental Chlorine Free) or TCF (Total Chlorine Free)?
Optical Brighteners (Pulp Suppliers Only)
Does your product contain any optical brighteners or fluorescence whitening agents (FWA)? If yes, please specify content.
Lacey Act (Pulp Suppliers Only)
If your product is imported, you must sign a separate compliance document administered by Expera.

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