Certi
fi
cate of Decontamination
! ! ! CAUTION ! ! !
This form must be visibly af
fi
xed to the outside of the package!
Legally binding statement
I/We hereby declare that the device and accessories contained in this package have been
cleaned and/or disinfected pursuant to current laws and regulations and that the information
provided in this declaration is correct and complete:
Company /
Institution:
Street and
number:
Postal code, city:
Department:
Name:
Telephone,
extension:
Fax:
Reason for return:
Thank you, this
will help us to
reduce costs.
Date
Signature
Company stamp
