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.