ANNEX IISupplementary provisions
ANNEX II FORM TO BE USED BY COUNTRIES THAT ARE NOT PARTIES TO THE MINAMATA CONVENTION ON MERCURY INTENDING TO EXPORT MERCURY, WHETHER IN PURE FORM OR IN MIXTURES, TO A MEMBER STATE FOR THE PROVISION OF CERTIFICATION ON THE SOURCE OF MERCURY 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 (i) Please indicate the intended total quantity of mercury whether in pure form or in mixtures to be shipped (ii) Please indicate the intended date(s) of shipment(s) 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: — Name — Title: — Signature — Date: