Print this pageCUSTOMER DECLARATION
CUSTOMER DECLARATION SHOWING THE USE(S) OF A CATEGORY 2 SUBSTANCE
(INDIVIDUAL TRANSACTIONS)
I/We,
Name...............................................................................................................................................................
Address............................................................................................................................................................
Registration No or reference .....................................................................................
Registered on .......................................(date) by................................................................................... .........
(name & address of authority)
have ordered from:
REAGENT CHEMICAL SERVICES LTD
Address
the following substance: POTASSIUM PERMANGANATE - CN Code - 2841 6000
(quantity).................................................................................................................
The substance will be used solely for..................................................................................................................
We confirm that the substance referred to above will only be re-sold or otherwise supplied to a customer on the
condition that the customer will furnish a similar declaration of use (individual or multiple).
Signed.................................................................... Name..........................................................................
(block capitals)
Position................................................................... Date...............................................................................
RCP19/2 (POTASSIUM PERMANGANATE)
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