Scientific Glassware Repair Request Form

Institution / Company Name:*

Department / Lab Name:

Contact Person:*

Phone Number:

Email:*

Item Details

Item 1 - Name

Item 1 - Glassware Description

Item 1 - Quantity

Item 1 - Estimated Value

Item 1 - Damage Description

Item 2 - Name

Item 2 - Glassware Description

Item 2 - Quantity

Item 2 - Estimated Value

Item 2 - Damage Description

Item 3 - Name

Item 3 - Glassware Description

Item 3 - Quantity

Item 3 - Estimated Value

Item 3 - Damage Description

Item 4 - Name

Item 4 - Glassware Description

Item 4 - Quantity

Item 4 - Estimated Value

Item 4 - Damage Description

Add Photo damaged item or items (if applicable) Allowed files jpg, jpeg, gif, png. Up to 5MB

Upload

Contamination Declaration (Mandatory)

To ensure the safety of our technicians, please indicate whether the item has been used with any of the following and describe decontamination procedures performed.

This glassware has been used with (check all that apply):*

Hazardous Chemicals
Biological Agents
Radioactive Materials
None (Clean Equipment)

Decontamination Method Used:

Customer Certification

I certify that the above items have been properly cleaned and decontaminated in accordance with applicable safety guidelines, and are safe to handle and repair.

Name:*

Date:*