Download Drug Non-Diversion Form - MS Word

Aquarium Drug & Chemical Non-Diversion Certificate
The form documents the purchase of certain chemicals and drugs commonly used in the ornamental aquarium trade
in addition to acknowledging such products will only be used as intended. Products marketed in the ornamental
aquarium trade are not to be used on food fish, sport fish, species being grown with an intent to be released in the
wild and is not intended for human use.
The use of any regulated drug or chemical products purchased from Everything Aquatic are to be used exclusively in
aquariums, tanks or ponds containing entirely ornamental species and not those intended for human consumption,
sport fishing or for the propagation or feeding of species intended for human consumption or sport fishing purposes;
and the aforementioned products will not be diverted or sold to any other person, organization or company for use
in or on systems and species used for, or intended for use on species for human consumption or for sport fishing
purposes.
The undersigned also agrees by signing this certificate that he/she and employees associated with or employed by the
business or organization represented, understands the restrictions placed on the sale of these aforementioned
products and those personnel responsible for the product use will be instructed in proper usage. The undersigned
agrees not to intentionally divert any of these products for any other use and have been instructed to establish and
maintain written records of the purchase and use of these products.
The undersigned by signing electronically or in writing acknowledges and understands the purposes of this declaration,
certification and affirmation is to actively prevent the diversion and use of such chemicals, drugs, medications,
antibiotics, therapeutants and treatments to the food fish industry, sport fishing industry, human medicine and
veterinary medicine.
Please complete form electronically and return to [email protected].
Individual or Business Name:
Title (if a business):
Address:
City:
Phone:
Signature:
State:
Zip:
Email:
Date: Click or tap to enter a date.
Type your name as you would normally sign. This electronic signature is the equivalent of your handwritten signature
Your order will begin processing once form is on file.