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Customer Information
Customer
Customer
Customer
Information
Information
Information
Company:
Address:
Email:
Equipment
Equipment
Equipment
Equipment
Product Description:
Failure Description:
Type of
Type of Return
Return
Type of
Type of
Return
Return
☐ Non-billable
☐ Billable
☐ Exchange
☐ Repair
Health and safety
Health and safety
Health and safety
Health and safety
The product has been exposed to the following substances:
(by selecting 'YES' you MUST complete the table to the right)
Toxic
Harmful
Corrosive
Reactive
Flammable
Explosive (
*
)
Radioactive (
*
)
Biological (
*
)
Oxidizing
Sensitive
Other Dangerous Substance
Goods
Goods Preparation
Preparation
Goods
Goods
Preparation
Preparation
If you have replied YES to one of the above questions. Has the product been purged? ☐ YES ☐ NO
If yes, which cleaning agent/method:
Has the product been drained from oil?
I confirm to place this declaration on the outside of the shipping box.
I declare that the above information is true and complete to the best of my knowledge and belief.
I declare that the above information is true and complete to the best of my knowledge and belief.
I declare that the above information is true and complete to the best of my knowledge and belief.
I declare that the above information is true and complete to the best of my knowledge and belief.
I understand and agree to the terms and conditions on page 2 of this
I understand and agree to the terms and conditions on page 2 of this
I understand and agree to the terms and conditions on page 2 of this
I understand and agree to the terms and conditions on page 2 of this document.
Name:
Position:
Date:
NOTE: If a product is received at Agilent which is contaminated with a toxic or hazardous material that was not disclosed, the
NOTE
NOTE
NOTE
customer will be held responsible for all costs incurred to ensure the safe handling of the product, and is liable for any harm or injury
customer will be held responsible
customer will be held responsible
customer will be held responsible
to Agilent employees as well as to any third party occurring as a result of exposure to toxic or hazardous materials present in the
product.
Agilent Part No.:
New PO # (Hard copy must be submitted with this form): _______________
☐ Upgrade
☐ Consignment/Demo
Substances (please refer to MSDS forms)
Substances
Substances
Substances
* Agilent will not accept delivery of any product that is exposed to radioactive,
biological, explosive substances or dioxins, PCB's without written evidence of
decontamination.
Trade Name
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES
Instructions for returning products
Contact Name:
Tel:
Agilent Serial No.:
Type of Process (for which the equipment was used)
☐ Calibration
☐ Evaluation
Chemical Name
☐ NO
☐ NOT APPLICABLE
document.
document.
document.
Authorized Signature:
Page 3 3 3 3 of 3 3 3 3
Vacuum Products Division
Fax:
Original Purchasing
Reference:
☐ Return for Credit
Chemical Symbol
CAS Number
the
the
the
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