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DILUMAT S® MA108201-C
72
Declaration of Decontamination
To be faxed or shipped with the device sent for repairs
In an effort to protect our partners against the dangers of
contaminated devices, we ask that you complete, sign, and return this
declaration to us.
Without this form properly completed, we cannot repair or calibrate the
device.
Device: ………………………………………………………………………………
Serial Number: ……………………………………………………………………
We declare:
-
That the shipped devices have been carefully rinsed and
decontaminated before shipment.
-
That the shipped devices present no risk of bacteriological,
virological, chemical or radioactive contamination.
-
That we are aware that shipping a contaminated device may be a
personal liability or a liability of the represented company.
Last Name: …………………………………………………………………………
First Name: …………………………………………………………………………
Title: …………………………………………………………………………………
Company: …………………………………………………………………………
Date: …………………………………………………………………………………
Signature: …………………………………………………………………………
Corporate Stamp
Phone: …………………………………………………………………………
Fax: ………………………………………………………………………………