ECOGREEN INDUSTRIES END USE STATEMENTThis END USE STATEMENT certifies that the Ethyl Alcohol being purchased is not for use in production of a beverage product.Company Name *Your Name *Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate / TimeSignature *Clear SignatureA copy of your unexpired DRIVERS LICENSE, STATE ID CARD, or US PASSPORT and your completed and signedEND-USER STATEMENT must be received before we ship out your order.DRIVERS LICENSE, STATE ID CARD, or US PASSPORT File Upload *NameSubmit
