Page
3
of
3
Vacuum Products Division
Request for Return Form
Customer information
Company :
Contact Name:
Address: Tel:
Fax:
Email:
Equipment
Product description
Agilent PartNo
Agilent Serial No
Original Purchasing Reference
Failure description
Type of process
(for which the equipment was used)
Type of return
Non Billable
Billable
New PO # (hard copy must be submitted with this form): ______________________________________
Exchange Repair Upgrade Consignment/Demo Calibration Evaluation
Return for Credit
Health and safety
The product has been exposed to the following substances:
(by selecting ‘YES’ you MUST complete the table to the right)
Substances
(please refer to MSDS forms)
*
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
Chemical name
Chemical Symbol
CAS Number
Toxic
YES
NO
Harmful
YES
NO
Corrosive
YES
NO
Reactive
YES
NO
Flammable
YES
NO
Explosive (*)
YES
NO
Radioactive (*)
YES
NO
Biological (*)
YES
NO
Oxidizing
YES
NO
Sensitizer
YES
NO
Other dangerous substances
YES
NO
Goods 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?
YES
NOT APPLICABLE
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 understand and agree to the terms and conditions on page 2 of this document.
Name:
Authorized Signature:
Position:
Date:
NOTE
: If a product is received at Agilent which is contaminated with a toxic or hazardous material that was not disclosed,
the 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 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.