FORM FOR GRANTING OR DENYING WRITTEN CONSENT, PURSUANT TO ARTICLE 4(1) OF REGULATION (EU) 2017/852 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL ON MERCURY, TO THE IMPORT OF MERCURY OR OF THE MIXTURES OF MERCURY LISTED IN ANNEX I TO THAT REGULATION

Note: This form applies to the import into the European Union of mercury and of mixtures of mercury with other substances, including alloys of mercury, with a mercury concentration of at least 95 % by weight, as listed in Annex I to Regulation (EU) 2017/852 on mercury (‘mixtures of mercury’). This form does not apply in the case of imports of mercury, or a mixture of mercury that, qualifies as or is considered to be waste within the meaning of Directive 2008/98/EC on waste (1).

Section A:   Contact information to be provided by the importing Member State

Name of the designated national focal point (2):

Address:

Tel.:

Fax:

Email:

Section B:   Contact information to be provided by the exporting country

Name of designated national focal point or responsible government official:

Address:

Tel.:

Fax:

Email:

Section C:   Shipment information to be provided by the exporting country

Section D:   Information to be provided by the importing Member State

What is the purpose of the import of the mercury whether in pure form or in mixtures? Please circle:

Section E:   Shipping information

Importer

Name of business:

Address:

Tel.:

Fax:

Email:

Exporter

Name of business:

Address:

Tel.:

Fax:

Email:

Section F:   Indication of consent by the importing Member State

Nature of consent, please circle:

Please use the space below to indicate any conditions, additional details or relevant information.

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Signature of the importing Member State designated competent authorities and date

FORM FOR CERTIFICATION OF THE SOURCE OF MERCURY, WHETHER IN PURE FORM OR IN MIXTURES, TO BE EXPORTED

Section A:   Shipment information to be provided by the exporting country

Section B:   Shipping information

Importer

Name of business:

Address:

Tel.:

Fax:

Email:

Exporter

Name of business:

Address:

Tel.:

Fax:

Email:

Section C:   Certification

In accordance with Article 3(8) of the Minamata Convention on Mercury, my Government certify that the mercury included in the shipment described in this form is not from primary mercury mining

Please, provide supporting information on the source of the mercury to be exported

Signature of responsible government official and date: