formforexportnotification.docVIP

Form for Export Notification Note: This export notification is provided by the exporting country according to Article 12 of the Rotterdam Convention. The importing country is kindly requested to acknowledge receipt of this export notification within 30 days of the date indicated in section 7. Reference Number: Exporting country Importing country SECTION 1 IDENTITY OF THE CHEMICAL SUBJECT TO THE EXPORT NOTIFICATION 1.1 Common name 1.2 Chemical name according to an internationally recognized nomenclature (e.g. IUPAC) 1.4 Code numbers 1.4.1 CAS number 1.4.2 Harmonized system customs code  1.4.3 Other numbers (if applicable, specify the numbering system)  SECTION 2 IDENTITY OF THE PREPARATION TO BE EXPORTED (Fill in Section 2 only in case of a mixture or preparation) 2.1 Trade name and name of the preparation 2.2 For each substance in the preparation that is subject to the export notification, concentration (%) and information as specified under SECTION 1 SECTION 3 INFORMATION CONCERNING THE EXPORT 3.1 Expected date of export (dd.mm.yy) 3.2 Foreseen category (industrial chemical or pesticide) and foreseen use in importing country 3.3 Name, address, telephone, fax and email of the importer 3.4 Name, address, telephone, fax and email of the exporter SECTION 4 INFORMATION ON HAZARDS AND /OR RISKS OF THE CHEMICAL AND PRECAUTIONARY MEASURES (Please provide information in the table below or attach a copy of the safety data sheet that covers the information required.) 4.1 Hazard classification (e.g. GHS, WHO, IARC, EU) 4.2 Information on hazards and/or risks 4.3 Information on precautionary measures to reduce exposure to and emission of the chemical 4.4 Further information that may be useful to the importing country or has been requested by it, if available 4.5 Reference SECTION 5 INFORMATION ON PHYSICO-CHEMICAL, TOXICOLOGICAL AND ECOTOXICOLOGICAL PROPERTIES OF THE C