HazMat Waiver Form

HAZARDOUS MATERIAL WAIVER FORM

You Must be 18 years or older to sign this form. Waiver is good for 1 year after date submitted. *Hazardous Materials can only be shipped within the Continental United States and MUST be shipped UPS Ground. Hazardous Materials CANNOT ship air.
Due to potential liability issues, we required this form to be filled out in its entirety and submitted to our office prior to shipping any hazardous material.
Todays Date*

MonthDayYear
Name*

First NameLast Name
Company Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
I am at least 18 years of age.*
Date of Birth*

MonthDayYear
E-mail*
Material I am Purchasing*
Type of Use*
Additional Material I am Purchasing
Type of Use
Signature*
By Submitting this form, I fully understand that the material I am purchasing is considered hazardous by The Department of Transportation and/or could cause bodily harm. I assume all responsibility for its legal safe use and proper storage. I cannot hold the Chemistrystore.com responsible for its usage.
I understand that submitting false information is against the law and I will be held responsible for my actions and in no way hold the Chemistrystore.com responsible.
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