# 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 (Text with EEA relevance), Annex IV: CUSTOMER’S STATEMENT

Extent: E+W+S+N.I.

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
(Fill in capital letters)
The undersigned,
Name (customer):
Proof of identity (number, issuing authority):
Authorised representative of:
Company (principal):
Value added tax or another company identification number/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:

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Source: https://www.legislation.gov.uk/eur/2019/1148/annex/IV (the official version)
Page: https://openlegislation.uk/eu-regulation-2019-1148/annex-IV
Contains public sector information licensed under the Open Government Licence v3.0. Source: legislation.gov.uk, The National Archives.