Declaration of Biological Products (Proof of Classification

Declaration of Biological Products (Proof of Classification)
Document de classification des produits biologiques
SHIPPER:
Name:
Address:
City:
Province:
Country:
Postal Code :
Country of origin:
RECEIVER:
Name:
Address:
City:
Province:
Country:
Postal Code :
Country of origin:
Emergency Contact name /Phone number:
/
CHECK ONE BOX/COCHER UNE SEULE CASE:
*Exempt human specimen

*Exempt animal specimen
This biological product is:
Non-Infectious/Not-Restricted


Biological Substance, Category B, UN 3373
Matières biologiques, Catégorie B, UN 3373
Dry Ice, UN 1845
Neige carbonique, UN1845


* Exempt Human/Animal Specimen were collected from healthy individuals/animals
Dry Ice as refrigerant / Neige carbonique comme réfrigérant: YES / NO 
Scientific name of the biological product / Nom scientifique du produit biologique:
Description and quantity of the biological product / Description et quantité du produit biologique:
Final use of the biological product / Usage final du produit biologique:
For research purposes only
In vivo
In vitro



Additional requirements: YES / NO 
If yes, please specify:
_________________________________________________________________________________________________
Shipper’s Signature
EHS reference # (BP)
EHS-FORM-005 v.4
Print name/Nom en lettres moulées
EHS Name
Date
Signature
Date(YYYY-MM-DD)
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