Proposition 65 Compliance Declaration Form
Use this form to declare whether your product, package, material, or service item may expose users to Proposition 65-listed chemicals.
Business Name
*
Declarant Full Name
*
First Name
Last Name
Declarant Email Address
*
example@example.com
Declarant Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Product / Package / Material / Service Name
*
Category of Item
*
Please Select
Product
Package
Material
Service
Other
Does this item contain or result in exposure to any Proposition 65-listed chemicals?
*
Yes
No
If yes, list all Proposition 65-listed chemicals present or potentially present.
Describe the primary method of potential exposure (e.g., inhalation, ingestion, skin contact).
Declaration Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Declaration
Should be Empty: