Note: You must complete the following form before returning the equipment, failure to do so may result in a refusal to accept the shipment and may cause delays in processing the service or repair. __________ __________ Returns (RMA) Number Date _____________________________________________ _____________________________________________ Customer Address _____________________________________________ _____________________________________________ Contact Name Contact Details _____________________________________________ _____________________________________________ Product/Serial Number Product Name/Description _____________________________________________ _____________________________________________ Contact Name Contact Details Description of problem/reason for return. (continue on separate page if necessary) _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Note: Blade must be removed from blade holder. Returns from outside the EU must be state as “Returns of Nominal Value.” Failure to do so will incur customs charges. The following Declaration of Decontamination status applies to all items returned to Campden Instruments. If the answers to Section A2 and all of the question in Section B are NO, then ignore Sections D to F. Otherwise all Sections must be completed. You must complete and sign the Declaration. A 1. Has the package been opened? YES NO 2. Has the product been used? YES NO B Has the product been exposed internally or externally to any of the following? 1. Biological Hazards (pathogenic viruses, bacteria, fungi etc.) YES NO 2. Radioactive Sources (If yes, DO NOT RETURN) YES NO 3. Chemical Hazard (mercury, salts, acids, bases etc.) YES NO 4. Rabies, BSE, CJD, nCJD etc. YES NO 5. Any Other Hazard (specify in section D) YES NO C Does your laboratory contain animals that need to be shielded against pathogens? YES NO D Provide details of any indicated hazards. Include details of names and quantities of agents, Material Safety Data Sheets and First Aid Information. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ E Describe your methods of decontamination, including agents used for this purpose. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ F Are there likely to be any areas of residual contamination? Please be specific. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Declaration I declare that the information given above is true and complete to the best of my knowledge and belief, and that I have taken all reasonable steps to ensure its accuracy. If there is any subsequent outbreak of an infectious agent in my laboratory, I will inform Campden Instruments immediately. _____________________________________________ _____________________________________________ Authorised Signature Date _____________________________________________ _____________________________________________ Name (Print) Position _____________________________________________ _____________________________________________ Phone Fax Return Address Campden Instruments, 4, Park Road, Sileby, Loughborough. LE12 7TJ. U.K.