Declaration of Use

Declaration of Use
150 Venture Blvd., Spartanburg, SC 29306  Phone: 864-574-8960 Fax: 864-578-7308 
E-mail: [email protected] www.venturemeasurement.com
Customer Information
Company Name:
Contact Name:
Site Address
Position:
Phone Number:
Email:
Product Information
Product Name
Part Number:
Description:
Serial Number:
Venture Sales Order#
Venture Part#
Declaration of Use
I, (the named), certify that the descried product has: (Choose One Option)

Not been used with or contaminated by a hazardous material.
(Hazard: Chemical, Biological, or Radioactive).

Been used with/exposed to:
(Description & Chemical Symbol)
If , please attach/submit applicable MSDS for each hazardous material
This has been decontaminated by the following method: (Describe for each hazardous material)
I understand that the information above is true and legitimate to the best of my ability and this product presents
no Health and Safety hazard to anyone whom may come in contact with it:
Signature:
Print Name:
-------------------------------------------------------------------
Date:
PLEASE FOLD HERE
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For Venture Measurement - Use only
Cust. Svc/Sales review:
Print Name:
RMA -
QA/Safety/EHS review :
Date:
RMA#________________
Print Name:
SO#
Date:
Receiving Special Instructions:
RETURN TO VENTURE MEASUREMENT - RMA PACKING SLIP
SHIP TO:
Venture Measurement
150 Venture Blvd
Spartanburg, SC 29306
PHONE 864-574-8960
RMA# ____________________
SO#
____________________
VM20150403 Rev B