Export of Substances on the Export Control List Regulations guidance document: combined notice of proposed export and export permit application

Please download, fill, print and send back the PDF version of the above form. This HTML version is provided for on-line reading.

Part 1: general information

Exporter

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

Importer

Name of importer: __________
Address: __________
Telephone number: __________
Fax number: __________
Email address: __________

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: _______
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 (DD/MM/YY): _______
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 product indicate:
    1. the name of the product: _______
    2. the 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 the calendar year, if applicable: _______
14. Is the substance exported as a "hazardous waste" or "hazardous recyclable material" under the Cross-border Movement of Hazardous Waste and Hazardous Recyclable Material Regulations? [  ] Yes  [  ] No

You must attach the 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 and in force for Canada, 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 name and civic address: _______________
       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
   3. as a laboratory analytical standard? [  ] Yes  [  ] No
4. Is the substance being exported contained in a product? [  ] Yes  [  ] No
     If yes,
   1. Is the substance incidentally present in trace amounts? [  ] Yes  [  ] No
   2. Was the product 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 the product: _______________

(Repeat part 4 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)

Part 5: exports of asbestos listed on the Export Control List

For all forms of asbestos notified in part 2 of this form and listed on the Export Control List, please complete the following:

Name of substance: ____________________

Is the substance being exported:

1. contained in a product that is a personal or household effect intended for your personal use? [  ] Yes  [  ] No
2. contained in a military equipment? [  ] Yes  [  ] No
3. for disposal of the substance or of the product that contains it?
   [  ] Yes  [  ] No
     If yes, please indicate:
       Facility name and civic address: _______________
       Method of disposal: _______________
4. contained in a product that was used before December 30, 2018? [  ] Yes  [  ] No
5. contained in a product that is exported in order to service military equipment, while that equipment is outside Canada for the purposes of a military operation and there is no technically or economically feasible asbestos-free alternative available? [  ] Yes  [  ] No
6. contained in a product in not greater than trace amounts? [  ] Yes  [  ] No
7. contained in a raw material that is extracted from the ground and this is exported:
   1. to manufacture a consumer product that contains asbestos in not greater than trace amounts? [  ] Yes  [  ] No
   2. to manufacture a product that is not a consumer product? [  ] Yes  [  ] No
   3. for a purpose other than manufacturing a product, if the material will not be sold as a consumer product? [  ] Yes  [  ] No
        If yes, please indicate (if known):
          Purpose of the export: _______________
8. for use in a laboratory for analysis, in scientific research or as an analytical standard? [  ] Yes  [  ] No
9. for display in a museum? [  ] Yes  [  ] No

(Repeat part 5 for each form of asbestos notified in part 2 of this form)

Attach supplementary sheets as necessary.

Part 6: declaration

I understand that I, as the exporter, assume full 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 information provided in this application is accurate and complete. I understand that information in this application may be released to the country of destination.