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
Certifi cate of decontamination
! ! ! CAUTION! ! !
This form must be visibly affi xed to the outside of the package!
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