Basf Coatings Raw Material Supplier Approval Form

BASF Corporation

HELPING MAKE PRODUCTS BETTER™

RETURN COMPLETED INFORMATION TO: / For BASF Product Regulations only:
BASF CORPORATION / SAP Code / Temporary Code / Permanent Code
26701 Telegraph Rd.

Southfield, MI 48034

HMIS

BI number

Attn: Mike Meyer
Email:
Fax # 248-948-2249

BASF COATINGS RAW MATERIAL REGULATORY CHECKLIST

Complete all sections; forward any changes to BASF. Attach additional pages as necessary

TRADE NAME: ______/ SUPPLIER CODE: ______
CHEMICAL NAME: ______/ WT/GAL or SPEC. GRAV. ______
SUPPLIER NAME ______/ BASF CONTACT/REQUESTOR ______
ADDRESS______/ PHONE ______
______/ BUSINESS UNIT ______
Supplier contact completing request (Name/Title & Phone)
Name/Title______
Phone ______/ RAW MATERIAL TYPE ______

ATTACH THE FOLLOWING (REQUIRED): MSDS, PRODUCT DATA SHEET AND PRODUCT HAZARD COMMUNICATION LABEL. Please provide any unpublished Toxicity study summaries (animal or eco-tox)

REGULATORY INFORMATION (Please verify compliance with the items listed below. N/A – not available)

SUBJECT / Yes / No / N/A / Comments
Global Chemical Inventories – Is the product (components) listed on the following inventories: / Please site exemptions, restrictions or other listings (polymer, low volume, NDSL,etc).
TSCA (USA)
EINECS (Europe)
DSL (Canada)
MITI/ENCS (Japan)
AICS (Australia)
KECL (Korea)
PICCL (Philippines)
China (draft)
Is the product subject to TSCA Sect. 4, 6, 7, 8d or 12 (b)
Is the product cleared for use in food contact applications in the USA or Other Countries / Please site specific regulatory reference and use limitations.
List substance and wt % (including trace) for any of the following in product except where included on full disclosure:
Heavy Metals (as As, Cd, Cr6+, Hg, Pb)
Azo-containing compounds (e.g., Azo dyes/pigments)
Organotin Compounds
Materials of animal origin /

If yes, please define

Materials of plant origin (Food Allergy concerns) / If yes, please specify.
Chemical Weapons Convention Scheduled chemicals /

If yes, which country, which component

Polybrominated biphenyls (PBBs) or ethers (PBDEs)
Halogenated Materials including Hexachlorobenzene (HCB), PCBs or other Persistant Organic Pollutants (POPs) / If yes, please identify by CAS and include the wt% in the product at any level

Phthalates identified by the following CAS numbers

[84-74-2] [117-81-7] [26761-40-0] [84-75-3] [85-68-7] [28553-12-0] / If yes, please identify by CAS and include the wt% in the product at any level
Natural Rubber Latex or silicone oils / If yes, initiate MOC
Is the product regulated for air, land or sea transport
Identify the country of origin. / Attach NAFTA Certificate of Origin (if USA, Mexico, Canada)

100%DISCLOSURE (HAZARDOUS – NON-HAZARDOUS COMPONENTS) CAS#, PMN#, OR STATE RIGHT-TO-KNOW NUMBERS AND TYPICAL % WT FOR ALL COMPONENTS. IF TRADE SECRET, PLEASE PROVIDE ADEQUATE CHEMICAL DESCRIPTION.

CHEMICAL DESCRIPTION / CAS# or PMN # or EAN # / % Wt

Attach additional sheets if necessary

BASF COATINGS RAW MATERIAL SUPPLIER APPROVAL FORM

Please complete the required information below:

REQUIREMENT

/ STATUS / COMMENTS

MSDS – Please send an electronic version of your 100% full disclosure MSDS to your BASF contact and to

Letter – Please send a letter stating material is silicone free to your BASF contact and to / Yes No MSDS
Yes No Letter / If not full disclosure MSDS, Supplier must send letter specifically stating material is free of silicone

Product Hazard Communication Label – Please provide a copy of the Product Hazard Communication Label.

/ Yes No

Product Data Sheet – Please provide a copy of the data sheet for this product.

/ Yes No

Shelf Life - Please provide an accurate shelf life for the product being approved.

/ Shelf Life ______
Unit (mth, yr) _____

Recertification Process – Please indicate your normal process for recertification of this material, should it exceed the designated shelf life.

/ Yes No / Please attach process

Supplier Agreement on Specifications – Please send the raw material control plan agreement.

/ Yes No

Certificate of Analysis – Please provide a copy of the Certificate of Analysis based on agreement.

/ Yes No

ISO9001 Certification – Is your company ISO certified? If so, please provide a copy of your certificate.

/ Yes No / If in-process
Expected certification date:______

Management of Change Process (MOC) – Please indicate your receipt and understanding of the MOC process.

/ Yes No

Delivery Requirements – Please indicate your receipt and understanding of BASF’s delivery requirements.

/ Yes No

Supplier Quality Report Card (SQRC) – Please indicate your receipt and understanding of your submission requirements for the SQRC.

/ Yes No

Contact Information Verified (below)

/ Yes No

Supplier Production Part Approval Process – Please be aware that your company may be contacted by BASF Supplier Quality to participate in a supplier PPAP for your product.

Supplier Contact Information – BASF requires both a General Contact and Requirements Coordinator designated. The General Contact is responsible for responding to any product nonconformities. They will also act as the communications liaison between your company and BASF. The Requirements Coordinator will be responsible for receiving and obtaining approval of our specifications designated on the BASF Raw Material Control Plan.

Please provide the following information:

General Contact / Requirements Coordinator
Name: / Name:
Title: / Title:
Address: / Address:
Phone: / Phone:
Fax: / Fax:
Email: / Email: