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Law
Enforcement Sales Restriction - Chemical Agents
Chemical
agents in certain sizes, formulations and/OR delivery systems are
restricted to law enforcement purchase only and
are not sold to the general public
In
order to ship restricted items to individual (non-agency) purchasers, we require authentication of
peace officer affiliation with a law enforcement or government agency. The form below can be
used to furnish such authentication.
To proceed, print this form with your
browser's print feature. Fill out the information and include a
photocopy of employment ID. Then Fax it to us. Once received, this information is
subject to verification and securely filed for future
purchases of such restricted items.
No restricted product will be shipped until
this information is received. All submitted information is considered confidential and will not be
released in any way.
| CopQuest
Order No.: |
________________________________ |
| Your Name: |
________________________________ |
Date: |
______________ |
| Agency/Employer: |
________________________________ |
Badge/ID
No.: |
______________ |
| Address: |
________________________________ |
Telephone: |
______________ |
| City, ST,
Zip: |
________________________________ |
Fax: |
______________ |
| Items to
be Purchased: |
__________________________________________________
__________________________________________________ |
|
I
certify that I am authorized to purchase and possess items
as described above. |
|
| Signature: |
_________________________________________________________ |
|
|
|
|
|
Photocopy
of Front
of agency/employment
Identification card here
(attach additional
page if ID does not fit here)
|
Photocopy
of Back
of agency/employment
Identification card here
(attach additional
page if ID does not fit here)
|
FAX COMPLETED FORM TO:
805-388-0771
or mail to CopQuest
Order Administration · 365 Camino Carillo, Unit A · Camarillo, CA
93012
|
