Hair Relaxer Claim Questionnaire Name First Last Check All The Boxes That Apply Manufacturers AFAM Concept, Inc. d/b/a JF Labs, Inc. Hawaiian Silky – Crème Conditioning No Lye Silky Smooth Sheen Relaxer Hawaiian Silky – Herbal No Lye Conditioning Relaxer System with Tea Tree & Avocado Oil – 2 Applications Vitale – Olive Oil Anti-Breakage Relaxer No Base with Shea Butter – Regular Strength Vitale Pro – New Texture Salon Exclusive Hair Relaxer Vitale Mo’Body – Shea Butter Sensitive Scalp Relaxer with Oatmeal Protein Vitale – Life and Body – Hair Relaxer with Aloe Vera – Smooth Silky Texture Other (please specify): Other(Required)Avlon Industries, Inc. Affirm Crème Relaxer Affirm Sensitive Scalp Relaxer Affirm Dry & Itchy Scalp Relaxer Affirm FiberGuard Conditioning Crème Relaxer Affirm FiberGuard Sensitive Scalp Conditioning Relaxer Other (please specify): Other(Required)Beauty Bell Enterprises, LLC f/k/a House of Cheatham, Inc. Africa’s Best Herbal Intensive No-Lye Relaxer System Originals by Africa’s Best Originals Olive Oil Conditioning Relaxer Organics by Africa’s Best Olive Oil Conditioning Relaxer System with Extra Virgin Olive Oil Originals by Africa’s Best Kids Originals Natural Conditioning Relaxer System Organics by Africa’s Best Kids Organic Conditioning Relaxer System Organics by Africa’s Best Kids Natural Conditioning Relaxer System Texture My Way Men’s Texturizing Kit Texture My Way Women’s Texturizing & Softening System Other (please specify) Other(Required)House of Cheatham, LLC Africa’s Best Herbal Intensive No-Lye Relaxer System Originals by Africa’s Best Originals Olive Oil Conditioning Relaxer Organics by Africa’s Best Olive Oil Conditioning Relaxer System with Extra Virgin Olive Oil Originals by Africa’s Best Kids Originals Natural Conditioning Relaxer System Organics by Africa’s Best Kids Organic Conditioning Relaxer System Organics by Africa’s Best Kids Natural Conditioning Relaxer System Texture My Way Men’s Texturizing Kit Texture My Way Women’s Texturizing & Softening System Other (please specify) Other(Required)L’Oréal USA, Inc./ L’Oréal USA Products, Inc./ SoftSheen-Carson LLC Dark and Lovely Beautiful Beginnings No-Mistake Smooth Relaxer Dark and Lovely Beautiful Beginnings No Mistake Curl Softener Dark and Lovely Healthy Gloss 5 Shea Moisture No Lye Relaxer Dark and Lovely Triple Nourished Silkening Relaxer Optimum Salon Haircare Defy Breakage No-Lye Relaxer Optimum Salon Haircare Amla Legend Relaxer Optimum Care Bodifying Relaxer Optimum Multi-Mineral Reduced pH Crème Relaxer Bantu No Base Relaxer Ultra Precise No-Lye Conditioning Relaxer Mizani Butter Blend Relaxer Mizani Butter Blend Sensitive Scalp Rhelaxer Mizani Butterblend Prosolvent Relaxer Mizani Classic Rhelaxer Mizani Sensitive Scalp Rhelaxer Care Free Curl – Cold Wave Chemical Rearranger Super Strength Look of Radiance Permanent Crème Relaxer Kit Other (please specify): Other(Required)Luster Products Company Luster’s Pink Oil Moisturizer No-Lye Conditioning Relaxer Luster’s Pink Oil Moisturizer Short Looks Texturizer Luster’s Pink Oil Moisturizer Smooth Touch Relaxer PCJ Kit PCJ No Lye Kit – Adult PCJ No Lye Kit – Children’s ShortLooks Colorlaxer Diamond Black ShortLooks Colorlaxer Passion Red ShortLooks Colorlaxer Sable Brown Other (please specify): Other(Required)McBride Research Laboratories Design Essentials Honey Nectar Relaxer Kit – Time Release Regular Strength Design Essentials Sensitive Scalp Relaxer System Design Essentials Regular Conditioning Relaxer Other (please specify): Other(Required)Namaste Laboratories ORS Olive Oil Built-In-Protection No-Lye Relaxer – Full Application ORS Olive Oil No-Mix Salon Formula Crème Relaxer ORS Olive Oil Ultra Nourish Crème Hair Relaxer ORS Olive Oil Built-In-Protection No-Lye Relaxer – New Growth ORS Olive Oil Zone Relaxer – Targeted Touch-Up No-Lye Hair Relaxer ORS Olive Oil Curl Stretching Texturizer ORS Olive Oil Crème on Crème Touch-Up No-Lye Hair Relaxer ORS Olive Oil Mild Touch Relaxer with 60% Lower Chemical ORS Olive Oil Texlax and Stretch Semi-Straightening System ORS Olive Oil Girls Built-In Protection Plus No-Lye Conditioning Hair Relaxer System ORS Olive Oil Girls Soft Curls No-Lye Crème Texture Softening System ORS HAIRepair No-Lye Conditioning Relaxer System with Cuticle Shield ORS Olive Oil Professional No-Lye Relaxer Kit ORS Olive Oil Professional Crème Relaxer Namasté Salon System Triple Emulsion Relaxer Namasté Salon System Crème Relaxer Namasté Salon System Conditioning Sensitive Scalp No-Lye Relaxer Namasté Salon System Crème Relaxer Salon Trial Pack (Other (please specify): Other(Required)Revlon, Inc./ Revlon Consumer Products Corporation/ Revlon Group Holdings LLC/ Revlon African Pride – No Lye Relaxer Kit African Pride – No Base Relaxer African Pride – Multi Length Texturizer Kit African Pride – Dream Kids No Lye Relaxer Kit All Ways Natural – No Lye Conditioning Crème Relaxer Kit Arosci Aromaphoric Relaxer System Crème Of Nature Relaxer Cream Crème Of Nature Relaxer Kit Argan Oil Crème of Nature Herbarich Conditioning Crème Relaxer System Kit Crème of Nature Herbarich Conditioning Crème Relaxer and Texturizing System Crème of Nature Herbarich No Base Relaxer Crème of Nature No Base Relaxer Crème of Nature No Lye Relaxer Crème of Nature Sodium Relaxer Kit Crème Of Nature Cni No Lye Relaxer Crème Of Nature Cni Sunflower & Coconut Oil – Creme Crème Of Nature Eden Relaxer Fabulaxer No-Lye Relaxer Fabulaxer Gro-7 Revlon Realistic No-Base Relaxer Revlon Realistic No Lye Relaxer Kit Other (please specify): Other(Required)Strength of Nature, LLC African Pride Olive Miracle Deep Conditioning Crème-on-Crème No Lye Relaxer 8 Salon Pack Touch-Ups African Pride Olive Miracle Deep Conditioning Curls & Coils Texturizer African Pride Olive Miracle Deep Conditioning Curls & Coils Texturizer With Aloe Deep Conditioner African Pride Olive Miracle Deep Conditioning No-Lye Relaxer One Complete Application African Pride Olive Miracle Deep Conditioning No-Lye Relaxer, One Complete Touch-Up African Pride Shea Miracle Texture Softening Elongating System African Pride Dream Kids Olive Miracle (4) Touch-Up Relaxer Kit African Pride Dream Kids Olive Miracle Relaxer African Pride Dream Kids Olive Miracle Touch-Up Relaxer Kit Dr. Miracle’s No Lye Relaxer Kit Dr. Miracle’s New Growth No-Lye Relaxer Kit Elasta QP Normal Relaxer Kit Elasta QP Normal Relaxer Kit 2 Applications Elasta QP Resistant Relaxer Kit Elasta QP Sensitive Scalp Kit 12 Application Economy Pack Elasta QP Sensitive Scalp Kit – 4 Applications Elasta QP No Base Crème Relaxer Elasta QP SOY OYL No-Base Relaxer Elasta QP SOY OYL 4 Application Anti-Dryness No Lye Relaxer Kit Elasta QP No-Base Relaxer Elasta QP Extra Body No-Base Regular Relaxer Elasta QP Extra Body No-Base Super Relaxer Gentle Treatment No-Lye Relaxer Gray Kit Gentle Treatment No-Lye Relaxer Just For Me Relaxer 1 Complete Touch Up Relaxer Just For Me 4 Application Salon Pack Relaxer Just For Me No-Lye Conditioning Crème Relaxer Kit Just For Me No-Lye Conditioning Crème Relaxer Kit with Coil & Curl Cream Just For Me No-Lye Conditioning Crème Relaxer Kit (Super) with Oil Moisturize Lotion Just For Me No-Lye Texture Softener System Just For Me No-Lye Texture Softener System with Hair & Scalp Butter Motions Classic Formula Smooth & Silken Hair Relaxer Motions Professional 12-Application Salon Pack Motions Silkening Shine No Lye Relaxer Kit Profectiv MegaGrowth Anti-Damage No-Lye Relaxer 2 Touch Up Application Profectiv MegaGrowth Anti-Damage No-Lye Relaxer 1 Complete Touch Up Application Profectiv Procision Relaxer Kit Regular Profectiv Relax and Refresh Kit Auburn Spice Profectiv Relax and Refresh Kit Cherry Fusion Profectiv Relax and Refresh Kit Jet Black Profectiv Relax and Refresh Kit Mahogany Brown Profectiv Relax and Refresh Kit Silky Black Pro-Line Comb Thru Texturizer Kit SmartPerm No-Lye Anti-Breakage Relaxer System SmartPerm No-Lye Anti-Breakage New Growth Relaxer System, Smart Grow Stimulator SmartPerm Smart Valu No-Lye Anti-Breakage Relaxer Kit, 4 Applications Smart Perm Smart Valu Smart Gro Stimulator New Growth No-Lye Relaxer with GroRehab 4 Applications S&B® Botanicals™ 2 Application Relaxer S&B® Botanicals™ No-Lye Sensitive Scalp Relaxer, 1-App S&B® Botanicals™ No-Mix Texturizer 2-App, with Deep Conditioner S&B® Botanicals™ No-Mix Texturizer 2-App S&B® Botanicals™ Relaxer 8-Touch Up Soft & Beautiful No-Lye Crème Relaxer Soft & Beautiful No-Lye Ultimate Conditioning Relaxer System TCB Naturals Conditioning Argan Oil Vitamin E & Olive No-Lye Relaxer TCB Naturals Conditioning Argan Oil Vitamin E & Olive No-Lye Relaxer, 2 Applications TCB No-Base Crème Hair Relaxer with Protein & DNA UltraSheen Supreme Conditioning No-Lye Relaxer UltraSheen Ultra Moisturizing No-Lye Relaxer UltraSheen Ultra Moisturizing No-Lye Relaxer, with Keratin Other (please specify): Other(Required)If other Manufacturer used but not listed above, please provide: Δ