Decontamination Certificate 123
Selecta
PBL200051, Rev J
Decontamination Certificate
Under the provisions of Postal Law, Title 18, United States Code, Section 1716, and Department
of Transportation regulations contained in CFR 49, Part 173.386 and 173.387, “etiologic agents,
diagnostic specimens and biological products…are nonmailable…”
The undersigned therefore certifies that the Lumenis equipment being returned herein by
Individual/Institution City, State, Country
has undergone decontamination with a commercially available germicide cleared for use as a
“Hospital Disinfectant” and is clean and free from biohazards, including—but not limited to—
human or animal blood, tissue or tissue fluids or components thereof.
The undersigned also agrees to reimburse Lumenis for any costs incurred in cleaning the enclosed
equipment, in the event said item(s) is/are received by Lumenis in a contaminated condition.
Model Model
Serial Number (if applicable) Serial Number (if applicable)
Lumenis RMR Number Lumenis RMR Number
Typed/Printed Name Position/Title
Signature Date
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