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Clearance form
A completed form must always be returned with the equipment!
This declaration must only be completed and signed by an authorized member of the technical
staff!
The equipment or its parts will only be repaired or serviced if it is accompanied by a correctly
completed and signed safety declaration form. The work could be delayed if no form is returned.
We hereby assure that:
1. The enclosed equipment
Type: _______________________________________________________________________________________________________
Serial No.: __________________________________________________________________________________________________
2. The equipment was thoroughly cleaned before being shipped.
3. There is no hazard due to residual contamination.
4. The details given in this form are correct and complete.
Company / Institute:
Street:
____________________________________________________________________
Tel:
_________________________________________________________________________
Surname, First name:
Date:
______________________________________________________________________
________________________________________________________________________________
Legally binding signature
Page 28
Safety declaration form
Legally binding declaration
is free from any
toxic
corrosive
microbiological
carcinogenic
explosive
radioactive substances
or other substances that may be harmful to health.
__________________________________________ _ _ _ _ _
____________________________________________
Postcode, Town:
___________________________________________________
Fax:
_______________________________________________________________________
Position:
________________________________________________________________
_______________________________________________________________________________
Company stamp
ProMinent
®
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