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 :