بلد الوجهة النهائية: ___________________ الحجم/الكمية: ________________ معلومات عن المنتج/التركيبة: ________________
Information for requests concerning use (information to be provided for all intended uses): Use for which exemption is requested: __________________________________________________ Name if company(ies) / institution(s) authorized to use the substance: __________________________ __________________________________________________________________________________ Envisaged quantity (kg/year): __________________________________________________________ Country of origin: ___________________________________________________________________ Source and quality of substance or formulated product (e.g. percentage of POP, formulation type): ___________________________________________________________________________________ Importance of specific use to society, including consequences of not making use of the requested exemption: ___________________________________________________________________________________ ___________________________________________________________________________________ Information on use:___________________________________________________________________ (a) For pesticides: Target organism:____________________________________________________________________ Routine applications: YES: ________ NO: __________ Emergency applications: YES: _________ NO: _________ Application technique: _______________________________________________________________ Anticipated frequency: _______________________________________________________________ Application amount (e.g. kg a.i. per hectare): ______________________________________________