Name of Facility, Plant Site or Trading Company
USC Code Number
The applicant company (“Company”) hereby requests authorization for the above named facility, plant site or trading company to view/submit CWC declarations and reports using the Internet. The Company understands that an electronic submission has the same legal force and effect as a written submission. The Company recognizes that in order to view/submit CWC declarations and reports, the Company must be subject to the jurisdiction of the United States. The Company further understands that each individual authorized to submit declarations and reports via the Internet on behalf of the Company will be assigned an account for his or her exclusive use. The Company also understands that a password (USC password) will be assigned to Company for use with the US Code number assigned to our facility, plant site or company for use by all persons authorized to submit electronically for the Company. On behalf of the Company, I have read and understand Section 711.7 of the Chemical Weapons Convention Regulations (CWCR).
The Company agrees that each submission made via the Internet shall constitute a certification that:
The Company hereby certifies that the individuals listed below are authorized by the Company to act for the Company to view or submit declarations and reports via the Internet.
Company Name: | ________________________________________________ |
Mailing Address: | ________________________________________________ |
Facility, Plant Site or Trading Company Name: | ________________________________________________ |
USC Code: | ________________________________________________ |
Facility, Plant Site or Trading Company Address: | ________________________________________________ |
Telephone Number: | ________________________________________________ |
Facsimile Number: | ________________________________________________ |
Corporate Officer's Certification:
I am the owner, operator or senior management official of the Company and have the power to bind the Company herein.
Signature _____________________________________________
Print/Type Name and Title _______________________________
Telephone Number_________________________________________
Account Holder Certification:
I certify that:
Employee Name | Title | Authorized Privileges* | Telephone Number | Email Address | Signature and Date |
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