Herbal Accents  P. O. Box 937  Alpine,  CA  91903

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,  P. O. Box 937  Alpine,  CA  91903

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

Copyright 1993-2011   Herbal Accents  All Rights Reserved  
 Herbal Accents mailing address: P.O. Box 937  Alpine, CA  91903-0937  
Please e-mail any questions to  sales@herbalaccents.com
 Last update:  Thursday September 22, 2011