Declaration by Importer of Control Products

HC Protected

Name and address of shipper:

Name, address and telephone number of consignee:
Telephone #:

Name, address and telephone number of importer if different from consignee:
Telephone #:

Instructions - Reporting required

• Type or print clearly.
• Complete and retain last copy.
• Two copies are to be attached to the customs entry.
• The Collector of National Revenue will forward the original to the nearest regional office of the Pest Management Regulatory Agency (See below).

All control products imported into Canada for sale or manufacture must be registered under the Pest Control Products Act. Those control products imported for research purposes should be so marked on the signed statement, as these are not subject to registration under the Act.

Description of Control Products

1. Registration Number - If the product has an assigned registration number under the Pest Control Products Act, show the number. For those products regulated under Schedule II of the Pest Control Products Act, state "Scheduled under the Pest Control Products Act".
2. Product Name and Active Ingredients - The brand and name of the product should be given in full. For each product, show the active ingredient(s) by common or chemical name and the amount of each active ingredient.
3. Quantity of Product - Express the amount of product by mass in kilograms or volume in litres.
4. Purpose for Importation - State the purpose for importation for each product as one of the following: for resale, for manufacturing purposes or for research purposes.

Requirements Under the Pest Control Products Act

Collectors of National Revenue may hold any control product until the provisions of the Act and Regulations made thereunder are properly conformed with and may refuse entry and may cause the deportation of any control product when advised by an inspector that it has not been registered by the Act or that its sale in Canada would be contrary to any of the provisions of the Act and Regulations thereunder.

Registration number PCP Act:

Product name, active ingredients and amounts:

Quantity (Kg, L):

Purpose for Importation (resale, manufacturing, research)

• Manufacturing
• Resale
• Research

Regional Offices of Pest Management Regulatory Agency:

• Suite 340, 33 Weldon St., Moncton, NB E1C 0N5
  Fax: (506) 851-7369
• Complexe Guy-Favreau, 200 boul., René-Lévesque Ouest,
  Tour Est, 6^e étage, Montréal, QC H2Z 1X4
  Fax : (514) 283-1844
• 255 Woodlawn Rd. West, Unit 109, Guelph ON N1H 8J1
  Fax: (519) 826-2129
• 510 Lagimodière Blvd., Room 136, Winnipeg, MB R2J 3Y1
  Fax: (204) 983-5547
• 2045 Broad St., 5^th Floor, Regina SK S4P 3T7
  Fax: (306) 780-6864
• 9700 Jasper Ave., Room 730, Edmonton, AB T5J 4C3
  Fax: (780) 495-2624
• 4595 Canada Way, Room 400, Burnaby, BC V5G 1J9
  Fax: (604) 658-3391

Dating stamp of point at which shipment cleared at customs:

I hereby certify that the information provided is complete and correct in respect of this shipment of control product(s) for entry into Canada.

• Broker
• Importer

Name:
Date and point of entry:
Signature:
E-mail Address:

The information is collected by Health Canada for the purpose of administering the Pest Control Products Act. Information may be accessible or protected as required under the provisions of the Access to Information Act.