STATEMENT BY END USER DETAILS STATED ON THIS FORM

STATEMENT BY END USER
We confirm that the products listed below will not be used for the production of
chemical weapons or narcotic drugs, as specified in The Chemical Weapons
(Prohibition) Act 1996 and the Misuse of Drugs Act 1975, Schedule 1, Parts 1
and 2.
Product No: _________________________ Quantity & Size_______________
Product Name: _____________________________________________________
The product/s are used by us/me exclusively for (e.g. the production of………..,
Quality Control, etc)
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Company___________________________Order Number____________________
Address______________________________________________________________
Phone Number_____________________ Fax________________________
Email________________________________
Full Name_____________________________________________________
Signature of Authorised Person:- …………………………………..
DETAILS STATED ON THIS FORM WILL BE MADE
AVAILABLE TO THE NEW ZEALAND POLICE UPON
REQUEST.