APPENDIX
XII Z366_V1.18_eng © Hermle Labortechnik GmbH
Redemption Form / Decontamination Certificate
Enclose at all returns of equipment and assemblies absolutely!
The complete, full declaration about the decontamination is a prerequisite for the assumption and further
processing of the return. If no corresponding explanation is enclosed, we carry out decontamination with costs at
your expense.
Surname; Last Name: _____________________________________
Organization / Company: _____________________________________
Street: _____________________________________
ZIP CODE: _____________ place:____________________
Telephone: _____________ fax:____________________
E-Mail: _____________________________________
Are the parts listed above in touch with the following substances?
Health endangering watery solutions, buffers, acids, alkalis:……….............. ..... Yes No
Potentially infectious agents: ………………………………………………………... Yes No
Organic reagents and solvent: ………………………………...……..................... Yes No
Radioactive substances: ………………………………………..… α.. β.. γ.. Yes No
Health endangering proteins: …………………………………….……………......... Yes No
DNA: ………………………………………………………………………………….…. Yes No
Have these substances reached the equipment/assembly? ………………………….. Yes No
If so, which ones:
________________________________________________________________
Description of the measures for the decontamination of the listed parts:
I confirm the proper decontamination:
Company/Dept ._____________ Place and Date: ____________________________________
Signature of the authorized person: ________________________________________
Decontamination Certificate of Goods Returned upon Delivery
Please fill out in block
capitals!
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