(Également disponible en français)

APPLICATION FOR A

CLAIM FOR EXEMPTION

(Confidential when completed)

Note:	In this application, "HMIRR" means the Hazardous Materials Information Review Regulations.

PART I – CLAIMANT INFORMATION

CLAIMANT NAME:
ADDRESS:
CITY:
PROVINCE or STATE:
COUNTRY:
POSTAL or ZIP CODE:
TELEPHONE:
FAX:
E–MAIL ADDRESS:

CONTACT PERSON:
TITLE:
TELEPHONE:
FAX:
E–MAIL ADDRESS:

MAILING ADDRESS OF CONTACT PERSON

(IF DIFFERENT FROM ABOVE)
ADDRESS:
CITY:
PROVINCE or STATE:
COUNTRY:
POSTAL or ZIP CODE:

LANGUAGE OF PREFERENCE

ENGLISH
FRENCH

CLAIMANT CATEGORY

SUPPLIER
EMPLOYER

CLAIM TYPE – CHECK APPROPRIATE BOX(ES)

This application is completed in respect of:
ORIGINAL CLAIMS
One original claim for exemption in respect of one
controlled product (paragraph 4(a) of the HMIRR)
More than one original claim for exemption in respect of
any number of controlled products (paragraph 4(b) of
the HMIRR)
REFILED CLAIMS
One refiled claim for exemption in respect of one
controlled product (paragraph 5(a) of the HMIRR)
More than one refiled claim for exemption in respect of
any number of controlled products (paragraph 5(b) of
the HMIRR)
PART II – CONTROLLED PRODUCTS INFORMATION

Note: This application has been designed to accommodate one or more than one claim for exemption in accordance with section 4 or 5 of the HMIRR.

For each controlled product included in the claim or claims for exemption, give the product identifier	Indicate Registry Number previously assigned (if applicable)	Indicate the subject of the claim for exemption by using the appropriate reference (i.e. A, B, etc.) listed in Part III of this application	Registry Number (for Commission use only)

PART III – SUBJECT OF CLAIM FOR EXEMPTION

SUPPLIER

A. Chemical identity of an ingredient of a controlled product

B. Concentration of an ingredient of a controlled product

C. Name of a toxicological study that identifies an ingredient of a controlled product

EMPLOYER

D. Chemical identity of an ingredient of a controlled product

E. Concentration of an ingredient of a controlled product

F. Name of a toxicological study that identifies an ingredient of a controlled product

G. Chemical name, common name, generic name, trade name or brand name of a controlled product

H. Information that could be used to identify a supplier of a controlled product

PART IV – INFORMATION THAT SUPPORTS THE CLAIM FOR EXEMPTION

(SEE SECTION 8 OF THE HMIRR)

Note: This Part seeks the basic information necessary for the Commission to review a claim for exemption. Under subsection 14(1) of the Act a screening officer may request a claimant to submit such additional information as the screening officer may require. If this application is filed in respect of more than one claim for exemption (section 4 or 5 of the HMIRR) and the information that supports the claims differs, a separate copy of this Part shall be completed in respect of each controlled product for which the information differs.
Do not disclose in this Part information considered to be confidential business information. If it is necessary to disclose such information in order to meet the requirements of this Part, do so on a separate sheet and enclose it together with a completed Part VII of this application in a separate sealed envelope.
1. Is the information required in this section and which is applicable to the claim(s) identical to that which has been previously provided?

YES (State Registry Number: )

If NO, complete the following:

(a) Number of employees, officers or directors of the claimant having

knowledge of or access to the confidential business information

(b) Number of the other persons [i.e., persons not referred to in (a)] inside or outside Canada

having knowledge of or access to the confidential business information

2. Measures taken to maintain the confidentiality of the information

Is the information in this section identical to that which has been previously provided?

YES (State Registry Number: )

If NO, answer the following:

(a) Is access restricted to persons on a "need to know" basis ? YES NO

(b) Are there confidentiality agreements for all individuals with

access to confidential business information? YES NO

(c) What other security measures, including those pertaining to site

security, document security and computer security, are employed?

3. COMPLETE EITHER (1) or (2)

(1) (a) Estimate of the material financial loss to the claimant that

would result from disclosure of the information ........................ ...................................................................................... $

(b) Explanation as to why the claimant considers the financial loss to be material:

(2) (a) Estimate of the material financial gain to the claimant's

competitors that would result from disclosure of the information .................................................................................... $

(b) Explanation as to why the claimant considers the financial gain to be material:

4. The amount of money and other business resources used to develop the information and the reasons why they are considered substantial in the circumstances.

PART V – FEE CALCULATION (SEE SECTIONS 4 TO 7 OF THE HMIRR)

Note:	Fees may be paid by certified cheque or money order, made payable in Canadian dollars to the Receiver General for Canada, or by credit card (Visa, Mastercard or American Express)
This Part has been designed to accommodate the calculation of the fee required to accompany claims for exemption in respect of each prescribed method of fee calculation. Select the appropriate description(s) set out below and calculate the total fee that is required to accompany the claim or claims for exemption that are being made.

1. Basic Fee calculations

(1) Fee in respect of one or more claims for exemption referred to in paragraph 4 of the HMIRR. Complete either section (a), (b) or (c) as applicable.

(a) For 1 – 15 claims

(i) $1,800 x (number of claims) max. $27,000 ...................................................................................... $

(b) For 16 – 25 claims

(i) $1,800 x 15 ..................................................................................................... $ 27,000

(ii) $400 x (number of claims minus 15) max. $4,000 ................................... $

Add lines (i) and (ii) .......................................................................................................................................... $

(c) For 26 or more claims

(i) $1,800 x 15 ....................................................................................................... $ 27,000

(ii) $400 x 10 ........................................................................................................ $ 4,000

(iii) $200 x (number of claims minus 25) .......................................................... $

Add lines (i), (ii) and (iii) .................................................................................................................................. $

(2) Fee in respect of claims for exemption referred to in paragraph 5 of the HMIRR [for any number of controlled products, all of which meet the definition of a Refiled claim set out in subparagraph 2(1)]. Complete either section (a), (b) or (c) as applicable.

(a) For 1 – 15 claims

(i) $1,440 x (number of refiled claims) max. $21,600 ........................................................................... $

(b) For 16 – 25 claims

(i) $1,440 x 15 ...................................................................................................... $ 21,600

(ii) $320 x (number of refiled claims minus 15) max. $3,200 .......................... $

Add lines (i) and (ii) .......................................................................................................................................... $

(c) For 26 or more claims

(i) $1,440 x 15 ......................................................................................................... $ 21,600

(ii) $320 x 10 .......................................................................................................... $ 3,200

(iii) $160 x (number of refiled claims minus 25) ................................................. $

Add lines (i), (ii) and (iii) .................................................................................................................................. $

(3) Total Fee [add amounts from sections (1) and (2)] ..................................................................................................... $

CLAIMANT IS TO SUBMIT TOTAL FEE UNLESS QUALIFYING CRITERIA FOR "SMALL BUSINESS" ARE MET (SEE FOLLOWING)

2. Fees for small businesses (section 7 of the HMIRR)

The fees for a claimant that meets the qualifying criteria of "small businesses" as set out in paragraphs 7(a) and (b) of the HMIRR are equal to one half of the fees calculated in section 1 of this Part.

(1) Eligibility as a small business

(a) Claimant's gross annual revenue, in the claimant's fiscal year immediately preceding the

fiscal year in which the claim for exemption is filed was more than $3,000,000............................... yes no

(b) Claimant employs more than 100 employees .............................................................................. yes no

Note: Where the answer to both paragraphs (a) and (b) is "no", the claimant is eligible as a small business.

(2) Fee for a small business claimant 1/2 x (amount of Total Fee, above) .................................................................. $

PART VI – DECLARATION

I, , hereby declare, on behalf of the claimant herein, that the information

(name)

reported in Parts I to V and Part VII of this application is true to the best of my knowledge and belief.

(signature)	(date)

(title)

PART VII – CONFIDENTIAL BUSINESS INFORMATION

Note: Complete this Part, place it in a separate sealed envelope and submit it together with Parts I to VI of this application.

Use more than one page if required.

ADDRESS CORRECTION

CLAIMANT NAME:	ADDRESS:
ADDRESS:	CITY:
CITY:	PROVINCE or STATE:
PROVINCE or STATE:	COUNTRY:
COUNTRY:	POSTAL or ZIP CODE:
POSTAL or ZIP CODE:
CONTACT PERSON:	TELEPHONE:
TITLE:	FAX:
E–MAIL ADDRESS:

PART A [for claims where subject matter pertains to the chemical identity or concentration of one or more ingredients in a controlled product under HMIRR subparagraph 8(1)(e)(i) and/or (ii) or 8(1)(f)(i) and/or (ii)]

Code name, code number or product identifier for each controlled product included in Part II	Generic chemical identity of the ingredient(s) for which exemption is claimed	CAS registry number of the ingredient(s) for which exemption is claimed (if available)	Confidential business information for which exemption is claimed (e.g., the specific chemical identity that is the subject of the claim for exemption)	Registry Number (for Commission use only)

PART B [for claims where subject matter is also or exclusively set forth under HMIRR subparagraph 8(1)(f)(iii) and/or (iv)]

NOTE: THIS PART IS NOT REQUIRED TO BE SUBMITTED IF NOT APPLICABLE TO THE CLAIM

Code name or code number of controlled product	Chemical name, common name, trade name or brand name which is part of the subject matter of the claim	Information that would be used to identify the supplier of the controlled product	Registry Number (for Commission use only)