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Guidance document for Export of Substances on the Export Control List Regulations

Forms for exporters - Combined notice of export and export permit application

Part 1: General information

Name of exporter:
Name of duly authorized representative:
Telephone number:
Fax number:
Email address:

Telephone number:
Fax number:
Email address:

For Environment Canada Use

Part 2: Identification of the substance or the product that contains the substance:

1. Name of substance as it appears on the Export Control List (Schedule 3 of the Canadian Environmental Protection Act, 1999):
2. Common name, if known:
3. Trade name, if known:
4. CAS registry number:
5. Commodity Code of the substance that is obtained from the Harmonized Commodity Description and Coding System: _______

Part 3: Export information

6. Country of Destination: _______
7. Expected date of export: _______
8. Estimated quantity of the substance to be exported: ____ kg
9. Purpose of Export: _______
    [  ] Destruction
    [  ] Industrial Chemical use
    [  ] Pesticidal use
    [  ] Other use
10. If the substance is contained in a manufactured product indicate:

  1. The name of the product:
  2. Concentration of substance in the product:

11. List the customs office through which the export is expected to exit Canada, if known: _______
12. List any countries through which the substance will transit, if known: _______
13. Proposed number of exports for this calendar year, if applicable: _______

You must attach the Material Safety Data Sheet for the substance being exported, or if applicable, for the product that contains the substance.

Part 4: Exports subject to the Stockholm Convention for substances listed on Part 2 or Part 3 of the Export Control List:

For all substances notified in Part 2 of this form which are found on Part 2 or Part 3 of the Export Control List and listed in Annex A or B of the Stockholm Convention, please complete the following:

Name of Substance: ____________________

  1. Specific exemption or acceptable purpose applicable to the substance being exported (if applicable): _______

  2. Is the substance being exported for environmentally sound disposal in accordance with paragraph 1(d) of Article 6 of the Stockholm Convention?
      [  ] Yes  [  ] No  If yes, please indicate:
        Facility: _______________
        Method of disposal: _______________

  3. Is the substance being exported for use:
    1. in a laboratory for analysis [  ] Yes  [  ] No
    2. in scientific research [  ] Yes  [  ] No; or
    3. as a laboratory analytical standard? [  ] Yes  [  ] No
  4. Is the substance being exported contained in a manufactured article? [  ] Yes  [  ] No
    If yes,
    1. Is the substance incidentally present in trace amounts? [  ] Yes  [  ] No
    2. Was the article containing the substance manufactured on or before the coming into force for Canada of a provision of the Stockholm Convention prohibiting, under Annex A, or restricting under Annex B, the production or use of that substance? [  ] Yes  [  ] No
      If yes, indicate the date of manufacture of article: _______________

(Repeat Part 3 for each substance notified in Part 2 of this form that is listed on Annex A or B of the Stockholm Convention and on Part 2 or Part 3 of the Export Control List)

Attach supplementary sheets as necessary

Send the application by email, facsimile or by mail to:
Minister of the Environment
c/o Chemical Production Division
Environment Canada
351 St. Joseph Blvd, 11th floor
Gatineau, Quebec
Facsimile: 819-938-4218

Section 10 of the Regulations describes exports that require the exporter to hold a valid export permit issued under the Regulations. A copy of the permit must be included with these exports in addition to the labeling prescribed by section 21.

A minimum 30-day prior notice of export is mandatory under section 5 of the regulations for all exports, including those requiring an export permit.

I understand that I, as the exporter, assume all responsibility for the removal of the substance from the country of destination and any related costs, including the transportation, care, control and storage of the substance, in the event that the exported substance is in contravention of any conditions set out in the export permit or if the export takes place after the export permit has expired or has been cancelled.

I declare that the above information is accurate and complete.  I understand that information in this application may be released to the country of destination.

Name of exporter or duly authorized representative (please print):



Date and Place:

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