Annex IV CUSTOMER’S STATEMENT

United Kingdom

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^f1

(Fill in capital letters)^f2

The undersigned,

Name (customer):

Proof of identity (number, issuing authority):

Authorised representative of:

Company (principal):

Value added tax or another company identification number^f3/Address:

Trade/business/profession:

Commercial name of the product	Restricted explosives precursor	CAS No.	Amount (kg/litre)	Concentration	Intended use

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:

Annotations

Footnotes

f1: Regulation (EU) 2019/1148 of the European Parliament and of the Council of 20 June 2019 on the marketing and use of explosives precursors, amending Regulation (EC) No 1907/2006 and repealing Regulation (EU) No 98/2013 (OJ L 186, 11.7.2019, p. 1).
f2: You can add the required rows in the table of substances.
f3: You can verify the validity of a VAT identification number of an economic operator through the VIES website of the Commission. Depending on the national rules on data protection, some Member States will also provide the name and address linked to the given VAT identification number as they are recorded in the national databases.