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Redemption Form: Decontamination Certificate
Decontamination Certificate of Goods Returned Upon Delivery
Enclose all returned shipping items and modules necessary!
The completely full declaration about the decontamination is 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
________________________________________________________________
Z167M_V1.18_eng
Serial No.
Description / Comment
APPENDIX
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
V
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