Unity Lab Services: Return Pipette Form

Primary Contact Information

* Fields marked with an asterisk must be completed.

First Name*

Last Name*

Email Address*

Business Phone*

Return Ship-to Address

Company*

Building/Department

Address 1*

Address 2

City*

ZIP/Postal Code*

Country*

Bill-to Address

Billing information same as return ship-to address

Company

Building/Department

Address 1

Address 2

City

ZIP/Postal Code

Country

Pipette Decontamination

Description/Condition of Equipment

Brand*

Model*

Serial Number*

Has the equipment been used?*

Yes

Is the equipment dangerous to one's health?

Yes

Cleaning/decontamination performed

(what type)?

Type of Contamination

Toxic*

Yes

Explosive*

Yes

Microbiological*

Yes

Radioactive*

Yes

Carcinogen*

Yes

Corrosive*

Yes

Bacteria*

Yes

Corrosive chemical hazard*

Yes

Virus*

Yes

Flammable chemical hazard*

Yes

Fungus*

Yes

Reactive chemical hazard

Yes

Pathogen*

Yes

Other harmful substances*

Yes

Please list all substances, gases, and by-products that may have come into contact with the equipment :

Trade name/product name/manufacturer

Chemical name/chemical symbol

Hazard classification

Precautions associated with substance

Containment first-aid measures

If any pipettes fail the Validation Fast Check, please contact us for recommended service options.

(If not checked, pipettes will be returned upon completion).

Calibration Interval

Please choose a calibration interval

3 months

6 months

9 months

12 months

Other

If other

I certify that the equipment described above has been thoroughly cleaned and decontaminated.

The dispatch of equipment will be in accordance with the appropriate regulations covering packaging, transportation and labeling of dangerous substances.

Payment Information

Purchase Order #

Phone or Email

(for copy of invoice)

Call for PO #

Quote Number

1 If major repair is needed, then a quote will be issued. Parts are extra.

2 Common PM parts include seal, o-ring, and lubrication. All other parts are extra.

Shipping cost may apply according to our terms and conditions.