Please fill-out this form legibly and completely.

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PURCHASE DETAILS
Product Name CAS No Pack Size TotalQuantity lnvoice no. /
Delivery Receipt
No.

DECTARATION

t, being
(Full Nome) (Designation in the Company)

on behalf of
(Complete Name and Address of Company / Institution)

declare that the above controlled chemical will be used as

(Spectfy in detail the intended use of the chemical)

Further declaring that aforecited controlled chemical will not be used for the manufacture of illicit
drug/s or diverted for illegal purposes. Further affirm that the company is amenable in the conduct of
inspection/verification of aforementioned by PDEA Regulatory Compliance Officers at any reasonable
business hours.

DETAILS OF BUYER'S IDENTIFICATION (Attach photocopy of presented identification with current photo)

Drivers License No: lssued at Valid Until

Company lD No: Valid Until

Contact Nos: (tel/ fax / email)

(Printed name and Signature / Date)

Noted by Next Higher Ranking Officer:

/'l

1. 2.
(Printed nome, Signature, Designotion/ Date) (Printed name, Signoture, Designotion/ Dote)

*:f**+****,1.***{.*******{.****'t**.***:*****;*****:f***************'}*********:t*******:*:t*:*:}********:****

EUD Reference No:

To be filled by Supplier
Received by:

On:

1
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