Application Form for Environment Management Release Notice of Toxic Chemicals

Name of application unit

  

Address of application institution  

 

Organization code of application institution  

 

Customs code of application institution

 

Name and Title of Applicant

 

Signature of Applicant

 

Contact Person

Name

 

Telephone

 

Fax

 

E-Mail

 

Mail address and postal code

 

Application date

 

Remarks

 

IUPAC Name

  Chinese

 English

Trade name (□ Pure substance □ Preparation, if preparation, then indicate the product preparation type)

 Chinese

 English 

Other Name

US CAS number

 

Degree of purity (%)

 

H.S. code

 

Quantity for Import

 

Usage of import chemicals

 

Package method

 

Import customs port and customs area code

 

Country/Region of Origin

 

Terms of trade

 

Despatch country (region)

 

Registration certificate number

 

Contract partner name

 

Contract Number

 

Receiving institute name

 

Organization code of receiving institute

Customs code of receiving institute 

 

Comments of pre-examination:

 
                                                   Seal

 

 

Pre-examination Institute:

 

 

Application Number

 

Release notice number