Declaration of harmlessness
Please copy and send in with your device!
Please display anon the outer packaging!
Declaration of harmlessness
(please fill out a separate form for each appliance)
We forward the following device for repairs:
Type of device: __________________________________________________________________
Part-no.: _______________________________________________________________________
Order-no.: ______________________________________________________________________
Delivery date: ___________________________________________________________________
Reason for repair: ________________________________________________________________
______________________________________________________________________
Medium used: ____________________________________ Properties:
irritant:
yes/no
corrosive: yes/no
We hereby certify that the machine has been thoroughly cleaned inside and out before its dispatch and that it is free from health risk chemical,
biological and radioactive materials as well as having been drained of oil. *)
If the manufacturer find it necessary to carry out further cleaning work, we accept the charge will be made to us.
We certify that the aforementioned information is correct and complete and that the unit is dispatched in compliance with legal requirements.
Company / address:
Phone:
�a�:
�a�:
E-Mail:
Customer-number:
Contact person:
________________________
____________________________
Date
Signature / stamp
*) If not applicable please cross out!
EN
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