8/12/2019 End Use Declaration

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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.

1 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 theRestricted Components Regulations.

The chemical product(s) being purchased is/are scheduled as restricted components (explosives precursors) per the Restricted ComponentsRegulations, and could be diverted to illegal end-uses. In accordance with the Restricted Components Regulations of Canada, .... ..... Canadarequires a signed and dated end-use declaration prior to selling or providing any restricted component to any person.

2 Furn ish ing ......... Canad a Facil ity : ......... Canada Inc., at(......... Canada CSR To Fil l Out)

Locat ion

Address

City / Prov / Postal Code

Enro l lment # xxxxxxxxxxxxxxxxxxxxxxxxxxxx

3 End-User

Name (Print) :

Company : SAP Customer Code :(......... Canada CSR To Fil l Out)

Address :

City / Prov / Postal Code :

4 Restr ic ted Compo nent Product or

Substance :

Product (Check Applicable)

Hydrogen Peroxide Nitr ic Acid

Potassium Nitrate Sodium Nitrate

SAP Product Code :(......... Canada CSR To Fil l Out)

5 Descr ipt ion of End Use /Descr ipt ion des ut i l izat ions f inales :

For end-uses other than explosives or

resel l ing, the purchaser must provide

both

(1) a copy of a bu siness l icence and

(2) photo ID issued by th e federal or

provincial or municipal

governm ent or by the employ er.

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 (Descr ibe) :

6Cert i f icat ion

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

8 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 : Attent ion : E-Mail :

Intended to meet the requirements of Sections 19 and 20 of the Restricted Components Regulations, SOR / 2008-47