Waters® SystemsQT™

Qualification Final Approval

© 2007 Waters Corporation
Certify that the system owner’s management reviewed the completed Waters ACQUITY
UPLC® system qualification protocols documented in the applicable installation, maintenance,
and operational qualification procedures. Acknowledge successful completion of the system
performance qualification, by completing Form 4.
Form 4 Qualification Final Approval
We, the undersigned owner’s management, reviewed this completed set of Waters ACQUITY UPLC system qualification
protocols. To the best of our knowledge, we believe they represent an accurate record of the installation, maintenance,
operational, and/or performance qualification of the instruments and software of the system being commissioned for use by

Company Name___________________________________________________________________________________

Owner’s System ID ______________________________

Performed and Accepted
Yes No Not Applicable Date

Installation Qualification
Manager’s initials Manager’s initials Manager’s initials

Maintenance Procedures
Manager’s initials Manager’s initials Manager’s initials

Operational Qualification
Manager’s initials Manager’s initials Manager’s initials

Performance Qualification
Manager’s initials Manager’s initials Manager’s initials

Any deviations from the recommended procedures were identified in the comments areas and were approved by an
owner-designated, responsible person.

Comments_______________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________

Manager___________________________________________________ __________________________________
Name (print) Signature

Title__________________________________________________________________________ Date ____________

(Owner-designated responsible person)

Manager___________________________________________________ __________________________________
Name (print) Signature

Title__________________________________________________________________________ Date ____________

(Owner-designated responsible person)

Manager___________________________________________________ __________________________________
Name (print) Signature

Title__________________________________________________________________________ Date ____________

(Owner-designated responsible person)

© 2007 Waters Corporation

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