"End User Certificate - Download Now DOC - DOC"
Singapore Customs, 55 Newton Road #07-02, Revenue House Singapore 307987 Tel No. : 6775 5137 Fax No. : 6775 5946 Email: firstname.lastname@example.org END-USER CERTIFICATE This set of forms may take you 10 minutes to fill in. You will need the following information to fill in the forms: Details of Scheduled Chemical(s) to be Exported Details of Exporter, Information on the Export and the Unique Reference Number of your Export Permit application TO BE COMPLETED BY EXPORTER (IN SINGAPORE) (1) Unique Reference Number of Export Permit application: (Unique Entity Number of Declaring Agent) (Date of Submission: YYYY/MM/DD) (Sequence Number) SECTION A DETAILS OF SCHEDULED CHEMICAL TO BE EXPORTED (2) IUPAC Chemical Name: (3) Percentage Purity: % (4) CAS Registry Number: (5) NA(CWC) Product Code: (6) Total Quantity: KGM (7) Harmonized System (HS) Code: SECTION B DETAILS OF EXPORTER (IN SINGAPORE) (8) NA(CWC) Licence Number: (9) Issued on: (DD/MM/YY) (10) Exporter (Company Name and Address): (11) Contact Person: (12) Designation: (13) Tel Number: (14) Fax number: (15) Company Stamp: (16) Signature/Date: SECTION C INFORMATION ON THE EXPORT (17) Transport Code (Please tick where applicable): (18) Bill of Lading/Airway Bill Number: (a) For Transfer by Sea (b) For Transfer by Road (c) For Transfer by Rail (d) For Transfer by Air (19) Final Destination: (20) Port of Discharge: SC-A-082 (Ver 4 - 07/11) Page 1 of 3 TO BE COMPLETED BY IMPORTER/ END USER IN RECIPIENT COUNTRY SECTION D PARTICULARS OF IMPORTER, END USER(S) FOR THE SCHEDULED CHEMICAL (21) Importer (Company Name & Address): (22) Contact Person: (23) Tel Number: (24) Fax Number: (25) Designation: (26) Actual End User of the Scheduled Chemical(s): Table 1A Tel Number, Company Name & Address End Use(s) of Scheduled Chemical Fax Number Please tick if more information is to Total Number of End User(s): provided on Table 1B. (27) I / We, representing _____________________________________________________________________ (Name of Company/ Organisation) hereby certify that: i) The Company / Organisation shall not export, re-sell or dispose any amount of the scheduled chemical declared in Section A outside the territory in the Receipient State or to any other person, natural or legal. ii) All the information provided in this End User Certificate are true and correct. iii) I / We shall update the information of the Actual End User in the event of any addition of End User(s) through my Singapore exporter, to the Office of the National Authority (Chemical Weapons Convention), Singapore. (28) Name of Importer: (29) Company Stamp: (30) Signature of Importer/Date: SECTION E: CERTIFICATION BY THE GOVERNMENT OF THE RECIPIENT STATE (31) Name of Government Official: (32) Department Name & Address: (33) Designation: (34) Tel Number: (35) Fax Number: It is hereby certified that the transferred Scheduled Chemical declared in Section A: i) Shall be used only for the purpose(s) not prohibited under the Convention on the Prohibition of the Development, Stockpiling and Use of Chemical Weapons and on their destruction. ii) Shall not be re-transferred or re-exported to other states. (36) Signature of Government Official / Date: (37) Department Stamp SC-A-082 (Ver 4 - 07/11) Page 2 of 3 ADDITONAL INFORMATION TO BE COMPLETED WHEN NECESSARY (CONTINUED FROM TABLE 1A) (38) Actual End User(s) of the Scheduled Chemical(s): Table 1B Tel Number & Company Name & Address End Use(s) of Scheduled Chemical Fax Number Total Number of End User(s): SC-A-082 (Ver 4 - 07/11) Page 3 of 3