EASTMAN Global Drug Precursor Form

Global Drug Precursor Customer ID Form

1.PRECURSOR CHEMICAL

2.IDENTIFICATION OF PURCHASER

Company Information

Company Contact Information


Ship-To Addresses

Please list all ship-to addresses for this chemical:

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Yes No

End Users and End Use Application of the Chemical

Please list the Names/Addresses of all End User(s). For the end use application of the chemical, describe the use in detail. If used in a manufacturing process, describe the product to be manufactured. If the goods or technology are ultimately intended for a military end use or military end user, a detailed description of the end use application must be appended when returning this form.

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Yes No
Describe the use in detail. If used in a manufacturing process, describe the product to be manufactured. If the goods or technology are ultimately intended for a military end use or military end user, a detailed description of the end use application must be appended when returning this form.

3.DISPOSITION OF USE OF ITEMS BY PURCHASER

PURCHASER named above certifies that the precursor chemicals purchased from Eastman:
Yes No
C.Will be RESOLD by PURCHASER within in the form in which received for use or consumption therein.
D. Will be RESOLD, outside of , by PURCHASER in the form in which received

4.PURCHASER REGISTRATION

Purchaser Registrations

Provide the registration number(s) and enclose the registration certificate(s) if:

  • You are registered to distribute, export, or import
  • There is a State or local government permit required for receipt or manufacturing

5.IMPORT PERMIT

(Note: Not applicable for domestic delivery within the United States or European Union)

Upload

6.AUTHORIZED PROCUREMENT REPRESENTATIVE(S)

Authorized Procurement Representative(s)

Please include all individuals who are authorized to place orders for this product. Orders will only be accepted from authorized individuals.

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7.PURCHASER CERTIFICATION

  • PURCHASER hereby certifies:
  • All purchased materials licensed or sold by Eastman Chemical Company and / or its subsidiaries will not be usedin any of the following applications or related activities:
  • Research on, or the development, design, manufacture, construction, testing, or maintenance of, nuclear explosive devices, or components of subsystems of such a device.
  • In “unsafe-guarded nuclear activities” or in unsafe-guarded or safeguarded nuclear fuel cycle activities.
  • The design, development, production or use of missiles.
  • The design, development, production, stockpiling or use of chemical or biological weapons.
  • In activities related to weapons of mass destruction, including production or use of nuclear weapons, materials, or facilities, missiles or the support of missile projects, and chemical or biological weapons.
  • Illicit narcotics activities of any kind.
  • For Reseller/Distributor/Trader the purchased materials will only be further distributed within their defined sales region.
  • Purchaser: by clicking the "I Agree" button you acknowledge that you have read and certify that all of the facts contained in the above statement are true and correct to the best of your knowledge and do not know of any additional facts which are inconsistent with the above statement.