Exporter’s Transfer

Country Code

Year

Transfer Number

Identification:

A. CHEMICAL TO BE TRANSFERRED:

Type:

IUPAC chemical name

CAS registry number

Total Quantity (Kilograms):

B. END-USE(S) OF THE CHEMICAL:

1.

2.

3.

C. END USER(S)

I (we) certify that I (we) am (are) the end user(s) of the chemical referred to under A above. I (we) will not export, resell or otherwise dispose of any amount thereof (1) outside the recipient State on whose territory the end user(s) listed below is (are) located, or (2) to any other person, natural or legal. I (we) further certify that, to the best of my (our) knowledge and belief, all of the facts contained in this certificate are true, and that I (we) do not know of any additional facts that are inconsistent with this certificate.

Name:

Quantity (Kg):

Position:

Organisation:

Address:

Signature:

Date:

Name:

Quantity (Kg):

Position:

Organisation:

Address:

Signature:

Date:

Name:

Quantity (Kg):

Position:

Organisation:

Address:

Signature:

Date:

D. CERTIFICATION ON BEHALF OF THE RECIPIENT STATE

It is hereby certified that the transferred chemical referred to above will be used only for purposes not prohibited under the Convention on the Prohibition of the Development, Stockpiling and Use of Chemical Weapons and on Their Destruction, and that it will not be re-transferred.

Name:

Position:

Organisation:

Address:

Signature:

Date: