Export of Substances on the Export Control List Regulations guidance document: 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: _______
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 the 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 known: _______

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

Attach supplementary sheets as necessary.

Part 4: 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.