Application for a Class B Precursor Registration

1. Applicant's Name

(if the applicant is a corporation, corporate name and any other name registered with a province)

• Name

Please provide a copy of your certificate of incorporation, or any document filed with the province stating the applicant's corporate name, and any other name registered with a province with this application, if applicable.

2. Registration Number

• (if renewal):
• I would like to renew my existing registration with no changes to the content of the current registration ( Complete sections 6, 7, and 8 only )

3. Preferred Language of Communication

• Verbal:
  • English
  • French
• Written
  • English
  • French

4. Applicant's Address

• 4A. If the applicant is a corporation, the address of their head office in Canada
  • Street
  • City
  • Province
  • Postal Code
  • Postal Address
  • Contact Person for this site (if this is a site where precursor activity will take place)
  • Telephone No.
  • Fax No.
  • E-Mail Address

  Please check the box if the location above is also a site where activities pertaining to Class B precursors take place. Please use "0" as the site number when completing Section 5 of this application form.

• 4B. If the applicant intends to conduct Class B precursor activities at a site other than at the above indicated head office, please provide the following information for each site.
  • Site 1
    • Street
    • City
    • Province
    • Postal Code
    • Postal Address
    • Contact Person for this site
    • Telephone No.
    • Fax No.
    • E-Mail Address
  • Site 2
    • Street
    • City
    • Province
    • Postal Code
    • Postal Address
    • Contact Person for this site
    • Telephone No.
    • Fax No.
    • E-Mail Address
  • Site 3
    • Street
    • City
    • Province
    • Postal Code
    • Postal Address
    • Contact Person for this site
    • Telephone No.
    • Fax No.
    • E-Mail Address
  • Site 4
    • Street
    • City
    • Province
    • Postal Code
    • Postal Address
    • Contact Person for this site
    • Telephone No.
    • Fax No.
    • E-Mail Address

Note: Please submit additional pages for additional sites, if needed.

5. List of Class B Precursor and Activity To Be Registered

• 5A. New Registration

  Please refer to section 4 and list the number that matches the information for the site to which the precursor activity will be conducted. For each precursor listed under each site, please specify the activity that is sought to be registered. If applicable, please provide information on classification of the products containing listed precursors.

  • Site Number
  • Name of precursor
  • Activity(ies) related to that precursor
    • Produce for sale
    • Import
    • Export
  • Classification of the products containing that precursor, if applicable. (eg. Paint)

  Note: Please submit additional pages if needed.

• 5B. Renewal

  In the case of a registration renewal, if the registered dealer wishes to add or delete a precursor or an activity at any site, please complete the table below.

  • Site Number
  • Addition / Deletion
  • Name of precursor
  • Activity(ies) related to that precursor
    • Produce for sale
    • Import
    • Export
  • Classification of the products containing that precursor, if applicable. (eg. Paint)

  Note: Please submit additional pages if needed.

6. Designated Personnel

• 6A. Senior Person In Charge (SPIC):
  • Surname:
  • Given Name:
  • Middle Name(s):
  • Position:
  • Gender
    • M
    • F
  • Date of Birth: (DD/MM/YYYY)
  • Telephone No.:
  • Fax No.:
  • E-Mail Address:

  Note: In accordance with Section 60(3)(b) of the Precursor Control Regulations, a criminal record check may be conducted for the Senior Person in Charge, when applying for a new registration or renewal, and at any time during the valid period of the registration certificate.

• 6B. Consent for Criminal Record Check

  In accordance with Section 60(3)(b) of the Precursor Control Regulations, the Senior Person in Charge (SPIC) must sign below indicating consent to having a criminal record check carried out for them by the RCMP through Health Canada with respect to a designated drug offence and a designated criminal offence.

  Category of Information for Disclosure and Authorized Consent: records of criminal convictions found in the Identification Data Bank attainable through the Canadian Police Information Centre (CPIC) for which no pardon has been granted.

  I agree to provide any information and submit to any means of identification* required to obtain the criminal record check.

  I agree to pay the fees established by the RCMP under the Criminal Record Verification for Civil Purposes Fee Regulations.

  • Signature of SPIC:
  • Date: (DD/MM/YYYY)

  * If inconclusive data is obtained, i.e. unable to confirm the identity of the SPIC through the name check, fingerprints will be requested.

7. Declaration(s)

I hereby declare that I have not, as an adult, been convicted in the previous ten (10) years of a designated drug offence, or of a designated criminal offence in Canada, nor in any other country, of an offence that would have constituted a designated drug offence or a designated criminal offence if committed in Canada.

• Name of Senior Person in Charge (SPIC):
• Signature:
• Date: (DD/MM/YYYY)

8. Statement

I hereby certify that the information and supporting documents provided are correct and complete to the best of my knowledge, and in accordance with the relevant sections of the Controlled Drugs and Substances Act (CDSA) and the Precursor Control Regulations (PCR).

I hereby certify that the internal controls pertaining to Class B precursors are sufficient to support a reliable system of record keeping in respect of the precursor activities and precursor inventory applicable to the registered dealer's precursor activity profile, and to permit the Minister to verify those activities.

I hereby certify that I am in a position of authority with respect to binding the applicant.

• Name of Senior Person in Charge (SPIC):
• Signature:
• Date: (DD/MM/YYYY)

9. Address

Please return the completed application form with all required documents to:

Chemical Precursors Section
Office of Controlled Substances
Health Canada
A.L. 0300B
Ottawa ON K1A 0K9

Additional Information - Statements to Accompany the Registration Application

Under Section 59 of the Precursor Control Regulations

• I hereby certify that I am familiar with the provisions of the Controlled Drugs and Substances Act and the Precursor Control Regulations.
• I hereby certify that I have sufficient knowledge concerning the use and handling of the Class B precursors dealt with by the registered dealer to which the registration applies, including the risk of those precursors being diverted to an illicit market or use.
• I hereby certify that all contact persons listed under each site specified in the application have a good knowledge of the Class B precursor activities carried out at the corresponding sites. All Contact persons also have a good knowledge of the use of handling of the relevant precursors, including the risk of those precursors being diverted to an illicit market or use

Under Section 90 of the Precursor Control Regulations

• I hereby certify that the necessary security measures will be maintained at all sites specified in the registration application, to ensure the security of the precursor(s) listed in this registration application.
  • Name of Senior Person in Charge (SPIC):
  • Signature:
  • Date: (DD/MM/YYYY)

Check List to Accompany the Application Form for
Class B Precursor Registration

This check list is provided to assist you on ensuring that all the required information has been included in your application for Class B Precursor Registration. Providing all the required information will avoid unnecessary delays in processing your application. Incomplete applications will be put on hold until the required information is received. If the latter is not received with the time period indicated, the application will be considered to have been withdrawn.

Please ensure the following information is completed in your application:

• Section 4: information for each site has been included.
• Section 5: included the classifications of the products containing that precursor, if applicable.
• Section 6B: signed by the Senior Person in Charge (SPIC).
• Section 7: signed by the Senior Person in Charge (SPIC).
• Section 8: signed by the Senior Person in Charge (SPIC).
• A copy of the certificate of incorporation, or any document filed with the province stating the applicant's corporate name and any other name registered with a province (if applicable).
• "Statements to Accompany the Registration Application" form is signed by the Senior Person in Charge (SPIC)