Declaration of Non-Engagement
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Notice with respect to certain aromatic amines and aromatic azo- and benzidine-based substances
Persons, including companies, that do not meet the requirements of the Notice with respect to certain aromatic amines and aromatic azo- and benzidine-based substances[*] are encouraged to complete this form and return the signed document to the address indicated at the bottom of this page.
Identification
Please replace, add or update the identification information
Please remove us from the database because we are no longer in business
Name of the person (e.g. company) :
_____________________________________________________________________
Canadian head office street address (and mailing address, if different from the street address):
_____________________________________________________________________
Federal Business Number[1]:
_____________________________________________________________________
Contact name for the Canadian Environmental Protection Act, 1999 (CEPA 1999) section 71 notices:
Mr. Ms. Dr.
_____________________________________________________________________
Title of contact:
_____________________________________________________________________
Contact’s street and mailing addresses (if different from above):
_____________________________________________________________________
Telephone number:
( _____ ) _____ - __________
Fax number:
( _____ ) _____ - __________
Email address:
_____________________________________________________________________
Non-Engagement Declaration
This person (e.g. company) was not engaged in the activities described in the Schedule 2 to the Notice, published in the Canada Gazette, Part I, on December 17, 2011.
_____________________________________________________________________
Name (print)
_____________________________________________________________________
Title
_____________________________________________________________________
Signature
_____________________________________________________________________
Date of Signature
Please return this form to the attention of the Substances Management Coordinator, Chemicals Management Plan:
200 Sacré-Cœur Boulevard,
Gatineau, Quebec
K1A 0H3
Telephone: (800) 567-1999 (Toll Free in Canada) or (819) 953-7156 (Outside of Canada)
Facsimile: (819) 953-7155
Chemical Substances Website
Footnotes
[*] Note: Requirements of the Notice are described in Schedule 2 to the Notice published in the Canada Gazette, Part I, on December 17, 2011.
[1] Federal business number is a nine-digit registration number issued by the Canada Revenue Agency (CRA) to Canadian businesses that register for one or more of the following: corporate income tax; importer/exporter account number; payroll (source) deductions (trust accounts); or goods and services tax. This number can be found on all forms issued to a business by the CRA. The first nine digits that appear on these forms is the Federal business number.