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APPENDIX
Redemption Form / Decontamination Certificate
Decontamination Certificate of Goods Returned upon Delivery
Enclose at all returns of equipment and assemblies absolutely!
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
XII
_____________________________________
_____________________________________
_____________________________________
_____________ place:____________________
_____________ fax:____________________
_____________________________________
Decontaminated object
________________________________________________________________
the
authorized
person:
Serial number
________________________________________
Z366_V1.18_eng
Describtion/comment
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
© Hermle Labortechnik GmbH
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