Master Distributor for GOEX POWDERS
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The following statement must be on file for each purchaser before Powder, Inc. will ship any order.

You may email a scanned image of the release
(the PDF file works great for that, printed out),
FAX the form to us,
or send it in the US Mail.

Powder, Inc.
1861 North College Ave.
Clarksville, AR 72830
Toll Free: (877) 833-1799
Fax : (479) 754-6281

Thank you.

Any questions about dealer orders, or other information, please call.

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STATEMENT OF RELEASE AND CERTIFICATION

  1. I certify that I am at least 21 years of age.
     
  2. I certify that all powder I purchase is solely intended for sporting, recreational, or cultural purposes.
     
  3. I certify that I am not purchasing Black Powder or ammunition for resale.
     
  4. I certify that no local or state ordinances prohibit my purchasing or possessing black powder or ammunition.
     

It is agreed that the purchaser named below shall hold Powder, Inc. harmless and indemnify it against: each and every loss; cause of action suit on account of purchaser; or damages to or loss of property of any third person growing out of purchaser's operations and or actions under this agreement or otherwise.

Purchaser:______________________________
<Printed Name>		Date:_____________
______________________________
<Signature>
Delivery Address:______________________________

______________________________
Contact Phone:______________________________
 
Contact Email:______________________________



If you have trouble printing this page, please try this file, a PDF file of this same information.

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