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Redemption Form / Decontamination Certificate
Decontamination Certificate of Goods Returned upon Delivery
Enclose all returned shipping items and modules necessary!
The complete, full declaration about the decontamination is a prerequisite for the assumption and further
processing of the return. If no corresponding explanation is enclosed, we carry out decontamination with costs at
your expense.
Surname; last Name:
Organization / Company:
Street:
ZIP CODE:
Telephone:
E-Mail:
Pos.
Quantity
1
2
3
4
Are the parts listed above in touch with the following substances?
Health endangering watery solutions, buffers, acids, alkalis:....................... .....
Potentially infectious agents: ..................................................................
Organic reagents and solvent: ..................................................................
Radioactive substances: .................................................. α.. β.. γ..
Health endangering proteins: ...................................................................
DNA: ..................................................................................................
Have these substances reached the equipment/assembly? ................................ Yes No
If so, which ones:
________________________________________________________________
Description of the measures for the decontamination of the listed parts:
I confirm the proper decontamination:
Company/Dept ._____________ Place and Date: ____________________________________
Signature of the authorized person:______________________________________
© Hermle Labortechnik GmbH
_____________________________________
_____________________________________
_____________________________________
_____________ place:____________________
_____________ fax:____________________
_____________________________________
Decontaminated Object
Z216M_V2.21_eng
Serial No.
Description / Comment
APPENDIX
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
VII
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