Declaration for the Import/Export of Biological Products Declaration
Transcription
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