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End-Use Declaration for Explosives Precursors

This document is an end-use declaration form for restricted components (explosives precursors) that must be filled out by purchasers and signed by an authorized person such as a manager or director. It requires the purchaser to provide their company and contact information, details on the restricted product being purchased and its intended end use, and a certification that the product will not be exported, resold, or provided to other entities in Canada. The completed form must then be returned to the supplier's customer service office.

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1K views1 page

End-Use Declaration for Explosives Precursors

This document is an end-use declaration form for restricted components (explosives precursors) that must be filled out by purchasers and signed by an authorized person such as a manager or director. It requires the purchaser to provide their company and contact information, details on the restricted product being purchased and its intended end use, and a certification that the product will not be exported, resold, or provided to other entities in Canada. The completed form must then be returned to the supplier's customer service office.

Uploaded by

e_wasted
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • End-Use Declaration Form

End-Use Declaration Restricted Components (Explosives Precursors)

Prepare under your letterhead. Must be signed by a person with authority a Manager or Director, of Operations or Regulatory.

End-Use Declaration Signed and dated In accordance with requirements of ......... Canada National xxxxx. Prepared to meet the requirements of S. 19 and 20 of the Restricted Components Regulations.

The chemical product(s) being purchased is/are scheduled as restricted components (explosives precursors) per the Restricted Components Regulations, and could be diverted to illegal end-uses. In accordance with the Restricted Components Regulations of Canada, ......... Canada requires a signed and dated end-use declaration prior to selling or providing any restricted component to any person.

Furnishing ......... Canada Facility : ......... Canada Inc., at


(......... Canada CSR To Fill Out)

Location Address City / Prov / Postal Code Enrollment # 3 End-User Name (Print) : Company : Address : City / Prov / Postal Code : 4 Restricted Component Product or Substance : Description of End Use / Description des utilizations finales :
For end-uses other than explosives or reselling, the purchaser must provide both (1) a copy of a business licence and (2) photo ID issued by the federal or provincial or municipal government or by the employer.

xxxxxxxxxxxxxxxxxxxxxxxxxxxx

SAP Customer Code :


(......... Canada CSR To Fill Out)

Product (Check Applicable)


Hydrogen Peroxide Potassium Nitrate Nitric Acid Sodium Nitrate

SAP Product Code :


(......... Canada CSR To Fill Out)

Explosives End-Use (Check)


If the end use for the restricted component is in explosives, purchase must provide licence, permit, certificate issued under the Explosives Act.

Reseller (Check)
If the restricted product is intended for resale, the purchaser must provide proof of enrolment on the list of sellers.

Other End-Use (Describe) :

Certification
I certify that I am the end user of the chemical product(s) referred to above for the purposes stated in this document. I wil l not export, resell or provide any amount thereof outside of Canada, or to any other entity within Canada.

Name (Print) : Signature : Position : Phone : Fax : E-Mail : **7** Date :


YYYYY / MM / DD

To be filled out by ......... Canada CSR before issuing to the purchaser.


Once filled out by purchaser, please return to Customer Service at the ......... Canada Sales Office. It is preferred to receive the declaration as an electronic attachment to an e-mail, otherwise a faxed copy will be acceptable.

Fax :

Attention :
Intended to meet the requirements of Sections 19 and 20 of the Restricted Components Regulations, SOR / 2008-47

E-Mail :

End-Use Declaration – Restricted Components (Explosives Precursors) Prepare under your letterhead. Must be signed by a

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