ANNEX IV
CUSTOMER’S STATEMENT
concerning the specific use or uses of a restricted explosives precursor as referred to in Regulation (EU) 2019/1148 of the European Parliament and of the Council ( 7 )
(Fill in capital letters) ( *1 )
The undersigned,
Name (customer):
Proof of identity (number, issuing authority):
Authorised representative of:
Company (principal):
Value added tax or another company identification number ( *2 )/Address:
_
Trade/business/profession:
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Commercial name of the product |
Restricted explosives precursor |
CAS No. |
Amount (kg/litre) |
Concentration |
Intended use |
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I hereby declare that the commercial product and the substance or mixture that it contains shall be used only for the indicated use, which is in any case legitimate, and will be sold or delivered to another customer only if they make a similar declaration of use, respecting the restrictions established in Regulation (EU) 2019/1148 for the making available to the members of the general public.
Signature: Name:
Function: Date: