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End-User Declaration
PDEA form for end-user declaration
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: END-USER DECLARATION (EUD)
Please fill-out this form legibly and completely.
PURCHASE DETAILS
Product Name
CAS No
Pack Size
Total Quantity
Invoice no. /
Delivery Receipt
No.
DECLARATION
I, _______________________________________being _______________________________________
(Full Name)
(Designation in the Company)
on behalf of ___________________________________________________________________________
(Complete Name and Address of Company / Institution)
declare that the above controlled chemical will be used as _____________________________________
_____________________________________________________________________________________
(Specify 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: ____________________ Issued at _________________ Valid Until_______________
Company ID No: _______________________________________________ Valid Until_______________
Contact Nos: (tel/ fax / email)_____________________________________________________________
_________________________________________________
(Printed name and Signature / Date)
Noted by Next Higher Ranking Officer:
1. ______________________________________
(Printed name, Signature, Designation/ Date)
2.______________________________________
(Printed name, Signature, Designation/ Date)
*********************************************************************************************
EUD Reference No:_______________
To be filled by Supplier
Received by:____________________
On:____________________________
END-USER DECLARATION (EUD)
For personal use
END-USER DECLARATION (EUD)
For personal use
Please fill-out this form legibly and completely.
Please fill-out this form legibly and completely.
PURCHASE DETAILS
Product Name
PURCHASE DETAILS
Product Name
Quantity
Quantity
DECLARATION
I, ________________________________________with
(Full Name)
residence address at____________________________
DECLARATION
I, ________________________________________with
(Full Name)
residence address at____________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
declare that the above controlled chemical will be used
for personal use as _____________________________
declare that the above controlled chemical will be used
for personal use as _____________________________
_____________________________________________
(Specify in detail the intended use of the chemical)
_____________________________________________
(Specify in detail the intended use of the chemical)
Further declaring that aforecited chemical will not be
used for the manufacture of illicit drug/s or diverted for
illegal purposes.
Further declaring that aforecited chemical will not be
used for the manufacture of illicit drug/s or diverted for
illegal purposes.
_____________________________________________
(Printed name and Signature / Date)
_____________________________________________
(Printed name and Signature / Date)
Valid ID No: ___________________________________
Valid ID No: ___________________________________
END-USER DECLARATION (EUD)
For personal use
END-USER DECLARATION (EUD)
For personal use
Please fill-out this form legibly and completely.
Please fill-out this form legibly and completely.
PURCHASE DETAILS
Product Name
PURCHASE DETAILS
Product Name
Quantity
Quantity
DECLARATION
I, ________________________________________with
(Full Name)
residence address at____________________________
DECLARATION
I, ________________________________________with
(Full Name)
residence address at____________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
declare that the above controlled chemical will be used
for personal use as _____________________________
declare that the above controlled chemical will be used
for personal use as _____________________________
_____________________________________________
(Specify in detail the intended use of the chemical)
_____________________________________________
(Specify in detail the intended use of the chemical)
Further declaring that aforecited chemical will not be
used for the manufacture of illicit drug/s or diverted for
illegal purposes.
Further declaring that aforecited chemical will not be
used for the manufacture of illicit drug/s or diverted for
illegal purposes.
_____________________________________________
(Printed name and Signature / Date)
_____________________________________________
(Printed name and Signature / Date)
Valid ID No: ___________________________________
Valid ID No: ___________________________________
