Declaration for the Import/Export of Biological Products Declaration

Complete this form and fax it back to Neil Starkey at (514) 848-3660
Declaration for the Import/Export of Biological Products
Declaration d’Importation/Exportation pour Produits Biologiques
Date: ____________________
To/À: Canadian Food Inspection Agency and/or Public Health Agency of Canada
Please find below the information needed to facilitate passage through customs/Voir ci-dessous les
informations necessaires pour faciliter le passage aux douanes
Exporter/Exportateur
Importer/Importateur
Name/Nom:______________________________
Name/Nom:______________________________
_________________________________
_________________________________
Address/Adresse:__________________________
Address/Adresse:__________________________
_________________________________
_________________________________
City/Ville:_______________________________
City/Ville:_______________________________
Prov/State/État:____________________________
Prov/State/État:____________________________
Country/Pays:_____________________________
Country/Pays:_____________________________
Postal Code/Zip/Code postale:_________________
Postal Code/Zip/Code postale:_________________
Country of Origin/Pays d’origine:________________________________
Scientific name and common name of the product/Nom commun et scientifique du produit: _____________________
____________________________________________________________________________________________
Description of the product/Description du produit:_____________________________________________________
____________________________________________________________________________________________
Check one box/
Cocher une seule case:
Check one box/
Cocher une seule case:
Check one box/
Cocher une seule case:
Check one box/
Cocher une seule case:
Infectious: □
Infectueux
Hazardous: □
Produit dangereux
Animal origin: □
D’origine animal
Used in vitro: □
À utiliser in vitro
Non-infectious: □
Non-infectueux
Non-hazardous: □
Produit non-dangereux
Non-animal origin: □
D’origine non-animal
Used in vivo: □
À utiliser in vivo
This product contains Bovinea SRM/ Ce produit contient du Bovinea SRM:
□ Yes/Oui
□ No/Non
Final use of the product/ Usage final du produit:_______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signature
Print name/Nom en lettres moulées
Date