Product return or servicing
Health & Safety Declaration Form
for Product Return or Servicing
Return authorization
number:
and/or
Service Ticket/Request:
To make sure the mutual protection and safety of Cytiva personnel, our customers, transportation personnel and our environment,
all equipment must be clean and free of any hazardous contaminants before shipping to Cytiva. To avoid delays in the processing of
your equipment, complete this checklist and include it with your return.
1.
Note that items will NOT be accepted for servicing or return without this form
2.
Equipment which is not sufficiently cleaned prior to return to Cytiva may lead to delays in servicing the equipment and
could be subject to additional charges
3.
Visible contamination will be assumed hazardous and additional cleaning and decontamination charges will be applied
Yes
No
Specify if the equipment has been in contact with any of the following:
Radioactivity (specify)
Infectious or hazardous biological substances (specify)
Other Hazardous Chemicals (specify)
Equipment must be decontaminated prior to service / return. Provide a telephone number where Cytiva can contact
you for additional information concerning the system / equipment.
Telephone No:
Liquid and/or gas in equipment is:
Water
Ethanol
None, empty
Argon, Helium, Nitrogen
Liquid Nitrogen
Other, specify
Equipment type / Product No:
Serial No:
I hereby confirm that the equipment specified above has been cleaned to remove any hazardous substances and that
the area has been made safe and accessible.
Name:
Company or
institution:
Position or job title:
Date (YYYY/MM/DD)
Signed:
Cytiva and the Drop logo are trademarks of Global Life Sciences IP Holdco LLC or an affiliate.
© 2020 Cytiva.
All goods and services are sold subject to the terms and conditions of sale of the supplying company operating
within the Cytiva business. A copy of those terms and conditions is available on request. Contact your local Cytiva
representative for the most current information.
For local office contact information, visit cytiva.com/contact.
28980027 AD 04/2020
To receive a return authorization number
or service number, call local
technical support or customer service.
8 Reference information
8.6 Health and Safety Declaration Form
Adjustable Oligo Column Operating Instructions 28967444 AC
39
