APPLICATION FOR A CLAIM FOR EXEMPTION

The following are step-by-step instructions for completing the Application for a Claim for Exemption. The information you supply using this application reflects mandatory information required under the Hazardous Materials Information Review Regulations. This information must be provided to the Commission before a claim for exemption can be considered and a registration number issued. This is only a guide. To access the application in a variety of formats, click here.

PART I – CLAIMANT INFORMATION

If the mailing address of the contact person in your organization is different from that of the claimant, enter the contact person’s address in this box.


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


CONTACT PERSON: Textbox
TITLE: Textbox
TELEPHONE: Textbox
FAX: Textbox
E-MAIL ADDRESS: Textbox


MAILING ADDRESS OF CONTACT PERSON (IF DIFFERENT FROM ABOVE)
CONTACT PERSON: Textbox
TITLE: Textbox
TELEPHONE: Textbox
FAX: Textbox
E-MAIL ADDRESS: Textbox
LANGUAGE OF PREFERENCE
ENGLISH Checkbox
FRENCH Checkbox
CLAIMANT CATEGORY

For the purpose of your claim(s), indicate whether you are the supplier of the controlled product(s) OR the employer using the controlled product(s) in the workplace. Only one claimant category should be checked.

SUPPLIER Checkbox
EMPLOYER Checkbox
CLAIM TYPE – CHECK APPROPRIATE BOX(ES)
This application is completed in respect of:

Claims for exemption come to the Commission either as ‘original claims’ or ‘refiled claims’ as defined in subsection 2(1) of the Hazardous Materials Information Review Regulations (see Glossary). Use this section to indicate the number of claims of each type that are included in a submission.

ORIGINAL CLAIMS
One original claim for exemption in respect of one controlled product (paragraph 4(a) of the HMIRR) Checkbox
More than one original claim for exemption in respect of any number of controlled products (paragraph 4(b) of the HMIRR) Checkbox
REFILED CLAIMS
One refiled claim for exemption in respect of one controlled product (paragraph 5(a) of the HMIRR) Checkbox
More than one refiled claim for exemption in respect of any number of controlled products (paragraph 5(b) of the HMIRR) Checkbox


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)

List each product identifier (see Glossary) for each controlled product in the claim or group of claims. The product identifiers must be identical to those appearing in both PART VII – CONFIDENTIAL BUSINESS INFORMATION and on the MSDS.

Do not list in this PART any information that you wish to keep confidential for the purpose of this claim.

 

If you indicate in PART I that you are a supplier of the controlled product(s), note the appropriate subject(s) of the claim or group of claims for exemption (i.e. A, B and/or C in PART III) with respect to each controlled product. If you indicate in PART I that you are an employer, then you must identify the appropriate reference(s) (i.e. D, E, F, G and/or H in PART III) which corresponds to the subject(s) of your claim or group of claims, with respect to each controlled product.

This column is for Commission use only. Do not enter anything here. A registry number will be assigned to each controlled product in this claim and forwarded to you along with the date of filing. IF all of the mandatory information has been correctly supplied at the time of application, a registry number will normally be issued to you by the Commission within three working days of receipt of the submission for a claim for exemption.



PART III – SUBJECT OF CLAIM FOR EXEMPTION

SUPPLIER

  1. Chemical identity of an ingredient of a controlled product
  2. Concentration of an ingredient of a controlled product
  3. Name of a toxicological study that identifies an ingredient of a controlled product

EMPLOYER

  1. Chemical identity of an ingredient of a controlled product
  2. Concentration of an ingredient of a controlled product
  3. Name of a toxicological study that identifies an ingredient of a controlled product
  4. Chemical name, common name, generic name, trade name or brand name of a controlled product
  5. 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?

If the information has been previously provided for the same product when previously registered please provide the registry number and Commission staff will cross-reference that information. This would also apply if the information has been previously provided for another product and would also be applicable to the current product. In which case, provide the registry number for the claim where the information was submitted.

Depending on the nature of the product and organization, persons having knowledge of, or access to, the confidential business information might include: president of the company and senior managers in charge of research and development, technical research staff, health and safety officers, or specific purchasing and warehouse staff, administrative support, accounting or costing personnel.

Other persons might include: external consultants and third-party preparers of company’s MSDSs and would include persons working for affiliated firms inside and outside of Canada.

It is preferable, but not mandatory, to use a profit oriented financial estimate approach to completing this section (gross profit, contribution margin, operation income, net income).

Yes Checkbox (State Registry Number: Textbox )
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 Textbox
(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 Textbox
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 Checkbox (State Registry Number: Textbox )
If NO, answer the following:
(a) Is access restricted to persons on a "need to know" basis? YES Checkbox NO Checkbox
(b) Are there confidentiality agreements for all individuals with access to confidential business information? YES Checkbox NO Checkbox
(c) What other security measures, including those pertaining to site security, document security and computer security, are employed?
3. COMPLETE EITHER (1) or (2)

To demonstrate materiality of financial loss or gain, provide an estimate of one of the following amounts for the whole company or applicable business unit: total gross profit (including product) and Net Income. Provide relevant qualitative factors which explain why above-noted financial estimate is considered to be material. Reference to more subjective impacts such as market share erosion or impact on product line completions can be included in this section.

(1) (a) Estimate of the material financial loss to the claimant that would result from disclosure of the information Textbox
(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 Textbox
(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.

The details of the amount of money or other business resources expended to develop the information should show how the claimant calculated the amount. This would include, for example, materials and services consumed, personnel costs, overhead costs, depreciation and amortization. Demonstrate that the expenditures were "substantial" in the circumstances by providing an estimate of one or more of the following:

  1. Potential sales of product
  2. Total annual R & D budget
  3. Number of years required to recoup R & D investment
  4. Other, please specify.

Also include any other reasons why the expenditure of the resources by the claimant are 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.

For a single claim for a controlled product which has not been previously filed with the Commission (‘an original claim’), the fee would be $1,800, for two original claims $3,600, for three original claims $5,400 etc. For the 16th through 25th claim submitted at the same time, there is a fee applicable of $400 per additional claim, i.e. for a submission of 16 claims, the applicable fee would be $27,400 (fee calculation = 15 x $1,800 plus 1 x $400 = $27,400). When more than 25 claims are submitted at the same time, the regular fee would apply to the first 15 claims, the reduced fee of $400 per claim would apply to the next ten claims (claims 16 through 25) and the fee applicable to those additional claims above 25 would be $200 per claim. i.e. for a submission of 27 claims the applicable fee would be $31,400 (fee calculation = 15 x $1,800 plus 10 x $400 plus 2 x $200 = $31,400)

(a) For 1 – 15 claims
(i) $1,800 x Textbox (number of claims) max. $27,000 $Textbox
(b) For 16 – 25 claims
(i) $1,800 x 15 $27,000
(ii) $400 x Textbox (number of claims minus 15) max. $4,000 $Textbox
Add lines (i) and (ii) $Textbox
(c) For 26 or more claims
(i) $1,800 x 15 $27,000
(ii) $400 x 10 (number of claims minus 15) max. $4,000 $4,000
(iii) $200 x Textbox (number of claims minus 25) $Textbox
Add lines (i), (ii) and (iii) $Textbox
(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.

For claims which have been previously filed with the Commission, there is now a reduced fee schedule for such refiled claims with the per claim fee beginning at $1,440 per claim for the first 15 claims. i.e. $1,440 for one refiled claim, $2,880 for two refiled claims, etc. For the 16th through 25th refiled claim submitted at the same time, there is a fee applicable of $320 for each additional claim. When more that 25 refiled claims are submitted at the same time, the applicable fee for each claim over 25 would be $160. i.e. for a submission of 27 refiled claims the applicable fee would be $25,120. (Fee calculation = 15 x $1,440 + 10 x $320 + 2 x $160 = $25,120)

(a) For 1 – 15 claims
(i) $1,440 x Textbox (number of refiled claims) max. $21,600 $Textbox
(b) For 16 – 25 claims
(i) $1,440 x 15 $21,600
(ii) $320 x Textbox (number of refiled claims minus 15) max. $3,200 $Textbox
Add lines (i) and (ii) $Textbox
(c) For 26 or more claims
(i) $1,440 x 15 $21,600
(ii) $320 x 10 (number of refiled claims minus 15) max. $3,200 $3,200
(iii) $160 x Textbox (number of refiled claims minus 25) $Textbox
Add lines (i), (ii) and (iii) $Textbox
(3) Total Fee [add amounts from sections (1) and (2)] $Textbox
CLAIMANT IS TO SUBMIT TOTAL FEE UNLESS QUALIFYING CRITERIA FOR "SMALL BUSINESS" ARE MET
2. Fees for small businesses (section 7 of the HMIRR)

If you meet the qualifying criteria for small business based on gross annual revenue and maximum number of employees the fee applicable to your submission would be one-half the normal fee. This small business fee reduction applies to both original claims and to refiled claims.

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 Checkbox no Checkbox
Claimant employs more than 100 employees yes Checkbox no Checkbox
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 Textbox (amount of Total Fee, above) $Textbox


PART VI – DECLARATION

I, Textbox, hereby declare, on behalf of the claimant herein, that the information reported in Parts I to V and Part VII of this application is true to the best of my knowledge and belief.

Textbox Textbox
(signature) (date)
Textbox
(title)


PART VII – CONFIDENTIAL BUSINESS INFORMATION

PART A and PART B are used to supply more precise details about the information that is the subject of the claim for exemption. PART A relates to confidential ingredient-based information and Part B relates to additional product- and supplier-based information which may be the subject of an employer claim. Where the subject of the claim for exemption relates to a toxicological study, the name and related description of the study would be included in Column 4 of Part A.

PART VII information should be sealed in a separate envelope marked CONFIDENTIAL BUSINESS INFORMATION (PART VII). If you have provided confidential information in PART IV of the Application or other information considered to be confidential, seal this information in this envelope along with the PART VII portion of the Application.


Note: Complete this Part, place it in a sepearte 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: Textbox
ADDRESS: Textbox
CITY: Textbox
PROVINCE or STATE: Textbox
COUNTRY: Textbox
POSTAL or ZIP CODE: Textbox
CONTACT PERSON: Textbox
TITLE: Textbox
ADDRESS: Textbox
CITY: Textbox
PROVINCE or STATE: Textbox
COUNTRY: Textbox
POSTAL or ZIP CODE: Textbox
TELEPHONE: Textbox
FAX: Textbox
E-MAIL ADDRESS: Textbox

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)

List the product identifier for each controlled product included in this claim (see Glossary). These product identifiers including, in the case of EMPLOYER claims, any code names or code numbers, must be identical to those listed in Part II of the application and on your MSDS.

If you are claiming for the chemical identity of an ingredient, the generic chemical identity of that ingredient must be indicated in this column and must be identical to the generic chemical identity that is used on your MSDS.

If the subject of the claim is the chemical identity of an ingredient and a CAS number is available for that specific ingredient it must appear in this column. CAS numbers are assigned by the Chemical Abstract Service Division of the American Chemical Society to individual chemicals, products of specified reactions, complex mixtures, etc.

The specific CBI, that is the subject of the claim for exemption, must appear in this column. For example, if the "chemical identity of an ingredient of a controlled product" is the subject of the claim for exemption and that chemical identity is, for example, propanol, then "propanol" must be shown in this column.

When the subject is the concentration, this column must contain for each ingredient the actual concentration or range of concentration as specified in CPR Section 11(3).

This column is for Commission use only. Do not enter anything here. A registry number will be assigned to each controlled product in this claim and forwarded to you along with the date of filing.

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)

Use this column to provide the coded product identifier used by the Employer to mask the identity of the controlled product. The coded product identifiers must be identical to those listed in Part II of the application and on your MSDS.

In this column provide the uncoded identity of the product.

In this column provide such information as the supplier’s name and address.

This column is for Commission use only. Do not enter anything here. A registry number will be assigned to each controlled product in this claim and forwarded to you along with the date of filing.



Payment of Fees

Payment can be made either by cheque, money order or credit card (Visa, Mastercard or American Express), in Canadian funds. Cheques or money orders should be made payable to the Receiver General for Canada.

Cheques or money orders sent to the Commission in currency other than in Canadian dollars can cause a delay in the issuance of the registry number and subsequent processing of your claim.

Submitting Your Claim

When you have completed PARTS I to VII:

  1. Insert PART VII and any other confidential information which you are providing into the envelope marked "CONFIDENTIAL BUSINESS INFORMATION (PART VII)" and seal this envelope.
  2. Insert in the mailing envelope:

The complete package must be sent either by registered mail, by courier or may be delivered in person to:

Hazardous Materials Information Review Commission
Client Services
427 Laurier Avenue West, 7th Floor
Ottawa, Ontario   K1A 1M3
Telephone: (613) 993-4331  Fax: (613) 993-4686
E-mail: hmirc-ccrmd@hc-sc.gc.ca