Declaration of Stakeholder Interest
Companies that do not meet the requirements of the Notice*, but who have a business interest in a substance in the “Challenge” are encouraged to identify themselves as stakeholders by completing this form. Companies who are not engaged in the activities described in the Section 71 Notices related to the challenge substances are encouraged to complete the batch specific “Declaration of non Engagement” Form.
*Note: Requirements of the Notice are outlined in Notice with respect to certain Batch 2 Challenge substances, published in Canada Gazette, Part I, on May 12, 2007
Identification
If your company received a letter announcing the “Challenge” initiative, please attach a copy of the letter.
Please replace or update the identification information indicated on the letter received at our name.
Please add this identification information as a new company, location and contact to the “Challenge” database.
Name of the company : ______
Canadian head office address: ______
______
Contact name for CEPA 1999 section 71 notices: ______
Title of contact: Mr. Ms. Dr. ______
Contact’s address (if different from above): ______
______
Telephone number: ______Fax number: ______
Email address: ______
Stakeholder Interest
Please retain our name on a list of stakeholders for the following substances (If space is insufficient, please attach a typed list):
CAS Registry Number(s) and Substance Name(s):
______
Type of interest: Import Manufacture of the substance Use/Application of the substance Use of the substance to make a mixture, product or manufactured item

Past or Potential Future involvement with the substance
CAS Registry Number(s) and Substance Name(s):
______
Type of interest: Import Manufacture of the substance Use/Application of the substance Use of the substance to make a mixture, product or manufactured item

Past or Potential Future involvement with the substance
CAS Registry Number(s) and Substance Name(s):
______
Type of interest: Import Manufacture of the substance Use/Application of the substance Use of the substance to make a mixture, product or manufactured item

Past or Potential Future involvement with the substance
Pursuant to section 313 of the Canadian Environmental Protection Act,1999, I request that the information that I am submitting
be treated as confidential.
______
Name (print) Title
______
Signature Date of Signature
Please return this form to: Minister of the Environment,
to the attention of the DSL Surveys Coordinator, Existing Substances Program
Place Vincent Massey, 20th Floor, 351 Saint-Joseph Boulevard, Gatineau, Quebec K1A 0H3
Telephone: 18882280530/819-9569313 – Fax : 1-800-410-4314/819-9534936 – Email: