FSN18001
ANNEX 1 RECEIPT CONFIRMATION (DISTRIBUTOR)
Reference to FSN 18001
Reference to FSCA 18001
Product Code: CAR POLE
From our data , it appear that some of these systems or carts have been provided to the users through your
company.
We kindly asked you to return via fax (at the number 041/5937011) or email at
this
page – filled and signed for acceptance – as soon as possible
Field Safety Notice Receipt
□ I confirm having received the Field safety Notice FSN18001 to be distributed to the customers
□ I confirm having distributed the Field safety Notice FSN18001 to the following customers:
HOSPITAL/ORGANIZATION
DATE
For confirmation
Name of the responsible person
Role and company
Signature
Date
Contact mail/phone
