1. Member of the general public (Name and address)

Name:

Identification Document Number:

Address:

Country:

Tel.:

Email:

2. Licence Number:

3. Licence for single use or multiple use (please tick)

single acquisition, introduction, possession and use of a restricted explosives precursor

name of the restricted explosives precursor(s):

maximum amount:

maximum concentration:

licensed use:

multiple acquisition, introduction, possession and use of a restricted explosives precursor

name of the restricted explosives precursor(s):

maximum amount in possession at any time:

maximum concentration:

licensed use:

4. If different than box 1 and required by national law, address where the restricted explosives precursor(s) will be stored:

5. If different than box 1 and required by national law, address where the restricted explosives precursor(s) will be used:

6. Indicate whether the restricted explosives precursor(s) is/are intended to be introduced or used (or both) in a Member State different from the Member State issuing this licence or outside the European Economic Area:

yes

no

Address:

Timeframe for the introduction or use (or both) of the restricted explosives precursor(s):