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Please read important policy information on Page 3 that applies to all returns.
1) CUSTOMER INFORMATION
Company Name:
Tel:
Customer Ship To:
Europe only: VAT reg. Number:
2) PRODUCT IDENTIFICATION
Product Description
3)
TYPE OF RETURN (Choose one from each row and supply Purchase Order if requesting a billable service)
3A.
Non-Billable
3B.
Exchange
Repair
4) HEALTH and SAFETY CERTIFICATION
AGILENT TECHNOLOGIES CANNOT ACCEPT ANY PRODUCTS CONTAMINATED WITH BIOLOGICAL OR EXPLOSIVE HAZARDS,
RADIOACTIVE MATERIAL, OR MERCURY AT ITS FACILITY.
Call Agilent Technologies to discuss alternatives if this requirement presents a problem.
The equipment listed above (check one):
HAS NOT pumped or been exposed to any toxic or hazardous materials. OR
HAS pumped or been exposed to the following toxic or hazardous materials. If this box is checked, the following
information must also be filled out. Check boxes for all materials to which product(s) pumped or was exposed:
Toxic
Corrosive
List all toxic/hazardous materials. Include product name, chemical name, and chemical symbol or formula:
________________________________________________________________________________________________________
NOTE: If a product is received at Agilent which is contaminated with a toxic or hazardous material that was not disclosed, the customer will be held responsible for all
costs incurred to ensure the safe handling of the product, and is liable for any harm or injury to Agilent employees as well as to any third party occurring as a result of
exposure to toxic or hazardous materials present in the product.
Print Name:
5) FAILURE INFORMATION:
Failure Mode (REQUIRED FIELD. See next page for suggestions of failure terms):
Detailed Description of Malfunction: (Please provide the error message)
Application (system and model):
I understand and agree to the terms of Section 6, Page 3/3.
Print Name:
SH-110 Dry Scroll Vacuum Pump
Email:
Agilent P/N
Billable
New PO # (hard copy must be submitted with this form):
Upgrade
Consignment/Demo
This page intentionally left blank.
Reactive
Flammable
Authorized Signature: ............................
Authorized Signature: ............................
Contact Name:
Fax:
Customer Bill To:
USA/Canada only:
Agilent S/N
Calibration
Explosive
Pg 2/3
Vacuum Products Division
Request for Return Form
(Health and Safety Certification)
Taxable
Non-taxable
Original Purchasing Reference
Evaluation
Return for Credit
Biological
Radioactive
Date:
Date:
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