End User Declaration Form

Full Name (as per IC/Passport) (required)

IC/Passport No. (as per IC/Passport) (required)

Address (required)

City (required)

Postcode (required)

State (required)

Contact No. (required)

Your Email (required)

Date of Order (required)

Subject (required)

Please select the type of controlled substance you'd like to buy below. *You can only purchase a maximum of 2kg controlled substance every 30 days from the invoice date.

Name of Poison (required)

Name of Poison (optional add-on)

Purpose of Purchase (required)

Invoice/Receipt Ref. No. (for office use only)

Signature of Purchaser

Photocopy IC/Passport (For first time purchaser only)

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