Form 1Form 1

Form 1

APPLICATION FOR ASSESSMENT OF A CHEMICAL UNDER SUBSECTION 55(1) OF THE INDUSTRIAL CHEMICALS (NOTIFICATION AND ASSESSMENT) ACT 1989

Name of applicant:

Address of applicant:

Details of chemical:

<table cellspacing="0" cellpadding="0" style="width:100%; border-collapse:collapse"><tbody><tr><td style="width:9.6%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>(1)</span></p></td><td style="width:75.02%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span>Chemical name of chemical:</span></p></td><td style="width:15.38%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p><span style="font-style:italic">(a)</span><span></span></p></td></tr><tr><td style="width:9.6%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>(2)</span></p></td><td style="width:75.02%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>Name or names by which the chemical is known:</span></p></td><td style="width:15.38%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span style="font-style:italic">(b)</span><span></span></p></td></tr><tr><td style="width:9.6%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>(3)</span></p></td><td style="width:75.02%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>Name or names under which the chemical is marketed by applicant:</span></p></td><td style="width:15.38%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span style="font-style:italic">(c)</span><span></span></p></td></tr><tr><td style="width:9.6%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>(4)</span></p></td><td style="width:75.02%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>Chemical Abstract Service Number:</span></p></td><td style="width:15.38%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span style="font-style:italic">(d)</span><span></span></p></td></tr><tr><td style="width:9.6%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>(5)</span></p></td><td style="width:75.02%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>Molecular formula:</span></p></td><td style="width:15.38%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span></span></p></td></tr><tr><td style="width:9.6%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>(6)</span></p></td><td style="width:75.02%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>Structural Formula:</span></p></td><td style="width:15.38%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span></span></p></td></tr><tr><td style="width:9.6%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>(7)</span></p></td><td style="width:75.02%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span>Gram</span><span>‑</span><span>molecular weight:</span><span></span></p></td><td style="width:15.38%; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt"><span></span></p></td></tr><tr><td colspan="3" style="padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt"><span style="width:141.75pt; font-family:'Lucida Console', monospace; font-style:italic; display:inline-block">.....................</span></p></td></tr><tr><td colspan="3" style="padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-left:15.85pt"><span>(Signature of applicant)</span></p></td></tr><tr><td colspan="2" style="border-bottom:1pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:3pt; margin-left:63.8pt; margin-bottom:9pt"><span style="font-style:italic">(e)</span><span></span></p></td><td style="width:15.38%; border-bottom:1pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:9pt"><span></span></p></td></tr></tbody></table>