South Australian Current Regulations

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CONTROLLED SUBSTANCES (POISONS) REGULATIONS 2011 - SCHEDULE 1

Schedule 1—Forms

End user statement

The chemical product I wish to purchase is classified as a possible illicit drug precursor or auxiliary reagent. I understand that to be supplied this product a signed end user declaration must be provided together with an order.


Catalogue No

Product Name

Quantity

Pack Size

Order No







Intended use:

☐Analytical

☐Research and Design

☐Manufacturing


☐Resale

☐Other


Please specify full details of assay, project, product customer etc

Purchaser details and declaration

I, [insert full name] being [insert position] on behalf of [insert name of company or institution and ACN]
Address:
Account No:
declare that the above chemical product will not be used for the manufacture of illicit drugs.

Signature:
Date:

Details of collecting agent's identification

Current Passport No:
Country of Issue:
Current Photograph Licence No:
Expiry date:
Photo Identification Card Type:

End user distributor/supplier details and declaration

I, [insert full name] being [insert position] on behalf of [insert name of company or institution and ACN]
Address:
Account No:
declare that the above chemical product will not be used for the manufacture of illicit drugs.

Signature:
Date:

Note—

1         Please attach a photocopy of current driver's licence bearing a photograph.

2         The form must be completed with all details.



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