Stakeholder Identification Form with respect to the Substance Groups Initiative of the Chemicals Management Plan
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Persons or organizations that have an interest in the substance groups being addressed through the next phase of the Chemicals Management Plan (CMP) may identify themselves as stakeholders for those substances by completing this form. Stakeholders will be informed of future decisions regarding these substances and may be contacted for further information.
Identification
I am interested in being consulted on the following group(s) of substances (please check all that apply):
- ☐ aromatic azo- and benzidine-based substances
- ☐ boron-containing substances
- ☐ boron-containing substances
- ☐ certain internationally classified substances with potential for exposure to individuals in Canada
- ☐ cobalt-containing substances
- ☐ methylenediphenyl diisocyanates and diamines (MDI / MDA)
- ☐ certain organic flame retardants
- ☐ phthalates
- ☐ selenium-containing substances
- ☐ substituted diphenylamines
Name of Person or Organization:
___________________________________________________________________
Federal Business Number (if applicable):
___________________________________________________________________
Address:
___________________________________________________________________
Canadian Head Office Address (if applicable):
___________________________________________________________________
Contact Name (Mr. / Ms. / Dr.):
___________________________________________________________________
Title of Contact:
___________________________________________________________________
Contact Address (if different from Head Office Address):
___________________________________________________________________
Telephone Number:
(_____) _______-____________
Fax Number:
(_____) _______-____________
Email Address:
___________________________________________________________________
Size of company:
- ☐ Micro (< 5 employees)
- ☐ Small (5 - 99 employees)
- ☐ Medium (100- 499 employees)
- ☐ Large (500+ employees)
Are you currently a member of a business or trade association? If yes, please specify:
___________________________________________________________________
Type of information in your possession that could help inform the risk assessment and/or risk management, as needed, of the substance groups:
___________________________________________________________________
Please return this form to:
Substances Management Coordinator, Chemical Management Plan
200 Sacré-Coeur Boulevard
Gatineau Quebec K1A 0H3
Fax: 819-953-7155
Email: Substances@ec.gc.ca
Questions? Contact Us:
Substances Management Information Line
Telephone: 1-800-567-1999 or 819-953-7156
Email: Substances@ec.gc.ca