Notification of substances and materials to

Arbejdstilsynet (The Danish Working Environment Authority)

Please forward the completed form to: Arbejdstilsynet, Produktregistret,

Postboks 850, 2100 København Ø, Denmark

1. Information on the notifying company (the company to which the PR-no. will be assigned)

Company name / CVR-no. (Danish companies only)
Address
Contact name, and e-mail address
Postal code and city
Country / Telephone no.

2. Information on the manufacturer

Company name
Address
Postal code and city
Country / Telephone no.

3. Information on the supplier (the company from which the notifier purchases the product)

Company name
Address
Postal code and city
Country / Telephone no.

4. The trade name and related item numbers for the substance/material

5. Information on the notifier

The form has been completed by (name, position and e-mail address)
Date Signature

6. Information on the composition

CAS no. or PR no. / Unequivocal chemical name or trade name for raw material / Weight-%
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material

6. Information on the composition

CAS no. or PR no. / Unequivocal chemical name or trade name for raw material / Weight-%
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material
PR-no. / Trade name
CAS-no. / Unequivocal chemical name
Manufacturer of raw material

7. Information on the technical function of the product

8. Information on trades or industries in which the product is used

9. Information on the customs tariff code (CN code)

10. Information on the manufactured or imported volume (only to be completed if the notifying company is Danish)

The expected volume per year in kilos or tonnes (Mark the unit with a cross)
Kilos  or tonnes 
Manufactured / Imported / Distributed on the Danish market / Exported from Denmark to other countries / Used in own company (the Danish notifying company)

11. Information on Danish importer(s) (to be used by foreign notifier)

Danish importer - company name, CVR-No.(The Central Business Register (CVR)), address and contact name and e-mail address

/

Volume imported per year

Danish importer- company name, CVR-No.(The Central Business Register (CVR)), address and contact name and e-mail address

/

Volume imported per year

Danish importer- company name, CVR-No.(The Central Business Register (CVR)), address and contact name and e-mail address

/

Volume imported per year

12. Information on danger labelling according to the CLP Regulation(Regulation (EC) No. 1272/2008 on classification, labelling and packaging of substances and mixtures with later adaptions)

GHS01 / GHS02 / GHS03 / GHS04 / GHS05 / GHS06 / GHS07 / GHS08 / GHS09

Signal word: DangerWarning

Hazard statement (Nos.) / Text
Precautionary statement (Nos.) / Text

Not labelled

13. Information on the physical state

14. Information on confidentiality

Point no. / Information to be treated as confidential / Enclosure

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