/ Application form
/ Official use**
(Y / N)
1 / 2 / 3
1Contact Addresses
1.1Applicant(future registration certificate holder) / Name:
Address:
Tel nr:
E-mail:
Applicants commercial register code:
1.2Manufacturer of Active Substance
/ Name:
Address:
Tel nr:
E-mail:
1.3Manufacturer of Product
/ Name:
Address:
Tel nr:
Fax nr:
E-mail:
1.4 Distributer in Estonia (If exists. Company who makes the product available in the Estonian market) / Name:
Address:
Tel nr:
E-mail:
2Identity of the Biocidal Product
2.1Trade name / Trade name of the biocidal product
2.2 Composition / Under subdivisions 2.2.1-2.2.7 bring out the corresponding information on 100% content of the biocidal product.
If relevant, then the content before mixing and final content of the product.
2.2.1Common name and function
Substance 1
Substance n / Also write the function for each substance (e.g active substance(s), impurities, inert component(s), stabilizer(s), etc), impurity of starting material.
2.2.2Chemical names
Substance 1
Substance n
2.2.3 CAS No.
Substance 1
Substance n
2.2.4EC No.
Substance 1
Substance n
2.2.5Structure or structural formula
Substance 1
Substance n
2.2.6Concentration of constituent(s)
Substance 1
Substance n / g/kg / g/L / % w/w / % v/v
2.2.7Classification of constituent(s)
Substance 1
Substance n / For each constituent (if relevant) state the classification and labelling as given in Annex VI of Regulation (EC) No 1272/2008 or state the manufacturers/ importers/ distributors classification done according to the criteria in Annex I of Regulation (EC) No 1272/2008.
2.3Physical state / Example: solution, emulsion , powder, aerosol or other
3Physical, chemical and technical properties *
3.1Appearance / Colour and odour
3.2 Explosive properties
3.3 Oxidizing properties
3.4Flash-point / Flash-point and other indications of flammability or spontaneous ignition
3.5 Acidity/
alkalinity / Acidity/alkalinity and if necessary pH value (1 % in water)
3.6Relative humidity
3.7Storage stability / Stability and shelf-life
3.8Technical characteristics / Technical characteristics of the biocidal product, e.g. wettability, flowability, pourability
3.9Physical and chemical compatibility / Physical and chemical compatibility with other substances/ products.
4Proposals for classification and labelling
4.1Hazard statement
4.2Precautionary statement
4.3Proposal for labelling
4.4Existing classification / The classification of preparations according to Regulation (EC) No 1272/2008.
5Effectiveness and Field of use envisaged
5.1Product type and field of use envisaged / State the number of the product type(s) as in Regulation (EU) No 528/2012 Annex V product type and the field(s) of use envisaged
5.2User(s) / Professional, non-professional, industrial
5.3Function
5.4Organism(s) to be controlled and products, organisms or objects to be protected / Include code(s) and term(s)
5.5 Required
documents / Instruction for use, safety data sheet
5.6 Other documents
Evaluation by Competent Authorities
Evaluation of documentation (data)
Documentation accepted as complete
Documentation not accepted as complete
Action required
*) Please don`t leave points 3.1- 3.9 empty. In case you don’t have information on that or you just
can’t find one, use “not available”.
In case this claim is not appropriate for that substance, use “not applicable”.
**) Official use column reserved for CA’s check (Y = Yes (accepted); N = No (not accepted))
Before submitting the application form we kindly ask you to remove from the fields the explanatory notes written in cursive.
Date
Signature of applicant
1
Registration on a transitional period