Chevron Phillips Chemical Company LP (CPCHEM) Page 1 of 2 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