INTENDED USE FORM

The form below is required to be kept on file in our office as per the DOT and Homeland Security Act These agencies govern the sale, usage and distribution of chemicals and regulate the reporting and recordkeeping procedures. A copy of your driver's license may also be required on certain chemicals. Please fill this out if your purchase requires one. A note in the DOT description area will tell you if this form is required. You may have several items that require this form so there are multiple lines to use. This form is required one time per chemical unless your use changes. Orders requiring this form are not permitted to be shipped until we have an Intended Use Form on file.

Thank you for taking your time to fill it out.

I, ________________________________________, have ordered the chemical(s) below and have identified my planned usage also. I confirm that the chemicals are being used in a safe and proper manner. The end product that you or your company may produce must conform to all local, state and federal rules and guidelines for usage and taxes that can be applied, are the responsibility of you and/or your company. Please complete and return.




Chemical Name Intended Use

1. ________________________ ______________________________

2. ________________________ ______________________________

3. ________________________ ______________________________

4. ________________________ ______________________________

5. ________________________ ______________________________

6. ________________________ ______________________________

7. ________________________ ______________________________



_______________________________________ ________________

Signature Date

Fax to: 804-403-6049

Email to: info@chemsavers.com