Declaration of Non-Engagement Form

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Notice with respect to certain methylenediphenyl diisocyanate and diamine, and phenol, methyl- substances

(PDF Version - 27 KB)

Persons, including companies, that do not meet the requirements of the Notice with respect to certain methylenediphenyl diisocyanate and diamine, and phenol, methyl- substances^[*] are encouraged to complete this form and return the signed document to the address indicated at the bottom of this page.

Identification

 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 June 16, 2012.

_____________________________________________________________________
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, 8^th Floor
Gatineau, Quebec 
K1A 0H3
Telephone: (800) 567-1999 (Toll Free in Canada) or (819) 953-7156 (Outside of Canada)
Facsimile: (819) 953-7155
Email: Substances@ec.gc.ca
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 June 16, 2012.
^[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.