Wholesale Application for Purchasing Nitrous Oxide
I/we confirm that all the details provided below to be factually and legally accurate information and have authorisation to fill out the company information that I legally work for in this documentation. I confirm that I will provide any further information required to prove the legitimacy of this information should I be asked to do so.
All information is required to be filled out; any missing information will result in your application being rejected. If you have any queries about the application, please contact us directly.
By filling out this document, you are consenting that the information provided will be kept on file by Cloverleaf Distribution Ltd in accordance with GDPR requirements. All data is held for use of Cloverleaf Distribution Ltd only and will not be sold on.
I/We confirm that we understand the law relating to the Psychoactive Substances Act 2016 (applicable to UK customers) and confirm that this application to purchase nitrous oxide is based on a legitimate legal use only and or is for legal use in the country that I/We are based within..
I/We understand that this application does not create a binding legal agreement or an invitation to treat and the application can be rejected at any time without further recourse should it not satisfy stringent legal and industry requirements.
I/We also agree to provide commercial business references to satisfy the supplier’s commercial due diligence requirements should this be deemed necessary to verify and substantiate the intended use.
I/We can confirm that all the information disclosed and prescribed on the form below is legally and factually correct and may represent an inducement for contractual relations. Any information that is subsequently deemed to be false, inaccurate or misrepresented and which was reasonably relied upon in entering into any subsequent supply agreement will be an actionable tort in accordance with any indemnity.
I/We confirm that I/we are duly authorised to complete this application on behalf of the business entity and have the implied authority to make statements herewith.
I/We confirm that I will provide any further information required to prove the legitimacy of this information should I be reasonably asked to do so.
All information required in this form is mandatory and I/we understand that any missing information will result in this application automatically being rejected.
By filling out this document, I/we are consenting that the information provided will be kept on or file in accordance with GDPR requirements. However I/We understand that at the request of the police information about an order may be divulged if there are concerns that the product is being misused or resold under illegal circumstances and therefore disclosure is necessary for the prevention or detection of unlawful acts.
If the above information is not yourself, please enter your own information below as you would personally be deemed as the ‘buyer’ for this wholesale account / purchase.
Statement 1.I confirm that I understand that inhalation of nitrous oxide carries a risk of serious health consequences and should not be re-sold to anyone for personal use. The risks of misuse relating to include narcosis, asphyxiation and death. The main effect of psychoactive substances is on the person’s brain, the major part of the central nervous system. By speeding up or slowing down activity on the central nervous system, psychoactive substances cause an alteration in the individual’s state of consciousness by producing a range of effects including, but not limited to: hallucinations; changes in alertness, perception of time and space, mood or empathy with others; and drowsiness.
Statement 2.I confirm that I am the named purchaser and that I am over the age of 18 years old and I am duly authorised to act on behalf of the company or trade stated.
Statement 3.I confirm that I do not propose to misuse the goods or intend to supply the goods to anyone I believe (i) to intend to misuse these products or (ii) are under the age of 18 years old.
Statement 4.I confirm that I will not knowingly use or recklessly sell these goods for its psychoactive effects.
Statement 5.I confirm that I will take all reasonable measures to ensure that the goods are used only in accordance with the manufacturer’s instructions. I acknowledge that the goods contain a manufacturer’s certificate of origin, with all labelling in strict accordance with EU 169/2011 EK regulations meeting Worldwide Food Standard requirements regulations and I will not tamper with the same.
Statement 6.I confirm that I will take all reasonable measures to ensure that the goods are kept in secure holding, so that they will not be accessible to minors or to misusers.
Statement 7.I confirm that should I plan to re-sell the goods, that all required signage, labelling and/or information which relates to or accompanies the Goods explains that it is for catering and / or any other legitimate use and does not suggest any form of misuse. I confirm I will not re-sell/deliver to suspicious locations including but not limited to hospitals, colleges and university locations unless legitimate use is duly verified and evidenced.
Statement 8.I confirm that I am aware of the HAZARDOUS nature of nitrous 0xide and will not interfere with the packaging to obscure any of the safety information and will take all necessary measures in regard to storage and transportation.
Statement 9. I confirm that the Goods will NEVER be put on board any type of aircraft and I will take due diligence measures to ensure that anyone I supply the goods to in accordance to this statement will take the same precautions.
Statement 10.I confirm that the N2O Chargers will never be heated in any way nor pierced by anything other than a certified whipping cream dispenser and I will take due diligence measures to ensure that anyone I supply the goods to in accordance to this statement will take the same precautions.
Statement 11.I confirm that as an retail re-reller I will take due-diligence when re-selling Nitrous Oxide and will ensure all precautions are taken to ensure the safety of the general public and of the ‘end-user’. I will request age identification from any customers wishing to purchase Nitrous Oxide and undertake stringent due-diligence to ensure that the products will not be misused. I will also ensure that any of my customers are subject to the same stringent terms and conditions that I am contracted to with the supplier.
Statement 12.I confirm that I will act to ensure due-diligent and regular research is taken upon my part to ensure I am abiding by UK and local regulations in regard to the sale of Nitrous Oxide including the Psychoactive Substances Act 2016 and I understand that I should seek my own legal advice.
Statement 13.I confirm that I will take all precautionary measures to monitor my online customers to ensure (a) that they are over the age of 18 years old and (b) that they are intending to use the N2O for legitimate purposes. I understand that as a re-seller or distributor, I could be committing a criminal offence should these goods recklessly fall into the wrong hands (ie. Minors or Misusers). I understand that The Psychoactive Substances Act 2016 defines ‘psychoactive substance’ and makes it an offence to produce, supply, offer to supply, possess with intent to supply, import or export psychoactive substances (the maximum penalty is seven years’ imprisonment).
Statement 14.I confirm that I understand that the use of these Goods is strictly limited to legitimate and lawful purposes and I agree to comply with the Psychoactive Substances Act 2016 and all applicable law and government guidance.
Statement 15.If I am deemed to have misused the goods or re-sold for misuse I understand that my business relationship will be terminated and subjected to a blacklist database so that I will not be able to contract with the supplier again. I understand that information may also be shared with the police should it be deemed appropriate for the protection of the public.
Statement 16.I confirm that I understand and will comply wholly with the aforementioned statements however nothing mentioned above or on the supplier website is construed as advice and I am to seek my own advice.
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Document Name: Wholesale Application for Purchasing Nitrous Oxide
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