Return certificate

Delivery address: For queries:

Please coordinate with KROHNE. repair.kmt@krohne.com
Fax: +49 203 301 4444

Reference no. (KROHNE): Reference no. (Customer):

This Certificate is for the purpose of compliance with legal requirements, as well as the protection of our employees and
premises. We can only process your order if this declaration has been completed, signed and returned to us. Please attach
the certificate to the outside of your package and ensure that it is clearly visible at all times.

Device/Sensor type: Serial number:

Medium: The following table must always be filled out completely, otherwise the processing is not possible!
Please indicate any dangers in accordance with the
Safety Data Sheet. The Safety Data Sheets must be
accompanied by the return.

Medium Conc. flammable acute toxicity irritation / health hazard aquatic corrosivity other hazards harmless /
[%] gases / liquids toxicity environment (please specify) unused

Medium
in process

Medium for
process cleaning

Medium for
final cleaning

Other hazards (e.g. biological threat, radioactivity, ...):

Shipping as dangerous goods: Yes No Dangerous goods class/number:

Description of the defect and other information:

Sender:
Company: Telephone:
Contact person: Fax:
Street: E-Mail:
Post code, City: Your order number:

I hereby confirm that the parts / devices contained in this return have been carefully cleaned and are depressurised.
This delivery does not contain residual amounts of dangerous goods.
Product may still contain residual amounts of dangerous goods.
In this case, please contact us before shipment: repair.kmt@krohne.com

Place and date Department Signature