Chevron Phillips Chemical Company LP (CPCHEM)
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INSTRUCTIONS: SOLD-TO CUSTOMER PROFILE
A. General Business Information
SOLD TO INFORMATION:
Customer Name:
Corporate Address:
City, State, Zip:
Country:
VAT number:
BILL TO INFORMATION:
Send invoices to:
Same as Sold to
SHIP TO INFORMATION:
Customer Name:
Ship to Address:
City, State, Zip:
Country:
EORI number:
If different from Sold to, please provide address where invoices should be sent:
Have purchases previously been made from Chevron Phillips Chemical
Company under a different company name?
Yes No
If YES, provide complete name & address of the company previously used
Has your FEDERALTAX ID changed? If yes, provide new Tax ID Number and Certificate
Yes
No
B. Contact Information
Order Acknowledgement Recipient
Invoice Recipient
Recipient Name
Title
Recipient Name
Title
Phone #
Fax # or Email Address
Phone #
Fax # or Email Address
C. Product Information (Select product(s), list the end uses and estimated annual volume)
Select desired product(s) below
Select CPChem Product Name
Select CPChem Product Name
Select CPChem Product Name
Other
End Use
Annual Volume
Select Unit of Measure
Select Unit of Measure
Select Unit of Measure
Select Unit of Measure
D. Documentation Requirements (Please indicate media for receiving documents)
SDS Recipient
Recipient Name
Title
Bill of Lading
Recipient Name
With shipment only
Title
COA prior to shipment
Recipient Name
With shipment only
Title
Do you have any internal codes to cross reference? Yes No
If yes, provide your code and Chevron Phillips Chemical Company
product name
Phone #
Fax # or Email Address
Phone #
Fax # or Email Address
Phone #
Fax # or Email Address
Select documents information to appear on
Code
Select CPChem Product Name
Code
Select CPChem Product Name
Code
Select CPChem Product Name
Code
Other
Any delivery requirements MUST be listed here or on your purchase order (i.e.: trailer/hose/fitting requirements, facility
operation hours, call requirements, etc.) If no requirements are provided, CPChem will not be responsible for delays in loading or
unloading.
Delivery Hours
Pallets
Shrink-wrap
Banding
Railcars/Strapping Chart
Bulk Requirements (please list on separate page)
Other
Form Revised 4/20/16
Chevron Phillips Chemical Company LP (CPCHEM)
Page 2 of 2
Please identify the person responsible for completion of this Product Stewardship self-assessment:
Name:
Title:
Telephone:
Email:
Date:
F. Product Stewardship Overview
1. Does your Company have a written Environment, Health, Safety, and Security management system?
YES (answer questions 2-6 of this section and do not complete section “G”)
NO (answer questions 4, 5 & 6 of this section and complete the Product Stewardship Questionnaire in SECTION “G”)
2. If yes, is the EHS management system tied to an Industry standard management system (i.e. Responsible Care, ChemSteward, ISO 14001)?
3. Name the EHS management system your company has committed to
4. Do you intend to register this product for REACh?
5. Does your Company physically receive the Product?
6. Product end use
Yes
Yes
No
No
Do you have specific people assigned responsibility to manage your EHS issues and compliance efforts?
If yes, please provide names and contact information?
Yes
No
Do you have processes in place for the development and identification of information regarding potential hazards
and risks associated with chemicals handled, distributed, manufactured, supplied, and purchased by your company?
Do you have a formal, documented EHS review of each product prior to approving for manufacture?
Do you have a formal, documented EHS review of each product prior to approving for commercialization?
Do you have a process to assess your Commercial Associates prior to doing business that includes EHS issues?
Yes
No
Yes
Yes
Yes
No
No
No
G.
Product Stewardship Questionnaire
1.
2.
Name:
Phone:
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Commercial Associates Include:
a. Contract Manufacturers
b. Suppliers
c. Distributors
d. Customers
Do you have EHS training programs in place for all employees based on regulatory requirements and job function?
Do you have a process in place to communicate hazard and risk information to:
a. Employees?
b. Customers?
c. Communities near your facility?
Do you have written procedures to manage the following:
a. Chemical hazards and exposures?
b. Emergency Response?
c. Chemical handling storage and disposal?
d. Standard operating procedures?
e. Worker protection?
f. New or modified products?
g. New or modified processes?
Do you have a process to track compliance with these procedures?
Do you have written auditing procedures to ensure compliance with applicable EHS laws and regulations?
Would a copy of your last completed audit be made available for review?
Do you have a process to ensure that audit findings are addressed and completed in a timely manner?
Orders can be submitted via email to: CCCNAO@CPCHEM.COM or fax to: 832-813-6112
Form Revised 4/20/16
Yes
Yes
Yes
Yes
No
No
No
No
NA
NA
NA
NA
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No