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Herbal Accents  1542 Fayette Street, El Cajon,  CA  92020

Because of potential liability problems, we are required to have this form signed and  mailed to our offices before we will ship any hazardous material.

HAZARDOUS MATERIAL WAIVER FORM

You must be 18 years or older to sign this form:

Date:__________________________

Name: _________________________________________________

Company Name (If Applicable): ____________________________________

Address:________________________________________________

City, State, Zip: ______________________________________

Phone Number: _____________________

Birth Date: ____________________________

E-Mail Address: __________________________________________________

Material I am purchasing: ___________________________________________

I fully understand that the material I am purchasing is considered hazardous and could cause bodily harm.  I assume all responsibility for its safe use and proper storage. I am at least 18 years of age.

Signed:                    ___________________________________________

Please Print Name:  ___________________________________________

Complete and sign this form and mail it to:
Herbal Accents,  1542 Fayette Street, El Cajon, CA 92020

You can also print out the form, fill it out and then e-mail it back as a PDF file.

Copyright 1993-2008   Herbal Accents   All Rights Reserved  
 Herbal Accents mailing address: P.O. Box 937  Alpine, CA  91903-0937  
Our new physical address is in El Cajon, California     Phone 619-562-2650
            our e-mail address is:  sales@herbalaccents.com    Last update: Monday June 23, 2008