Supplier Number. For Philips Medical Systems (PMS) only Relevant Substances: (Request for dispensation is not required) SUPPLIER confirms that, on the execution date of this Declaration, the Product, Part or Packaging indicated below as supplied to PMS contains Relevant Substance(s) in excess of the thresholds identified in the List of Relevant Substances for Product, Parts and Packaging below. • For environmental improvements, end of life and customer information, a relevant substance in excess of the threshold must be declared. • Only declare relevant substances in the Product, Part or Packaging when the concentration is above the threshold levels as indicated in the List of Relevant Substances for Products, Parts, Packaging below. Product (Philips Numbering Code): SUPPLIER code: Product weight: kg / gr: Please check all that apply Relevant Substances for Products, Parts and Packaging Threshold value in ppm (mg / kg) Amount present in grams Aromatic Hydrocarbons, Halogenated 10 Antimony and -compounds 10 Arsenic and -compounds 10 Beryllium and -compounds 10 Chromium(VI) -compounds 1000 Cobalt and -compounds 10 Lead and -compounds (Cables and Printed Circuit Boards excepted) 1000 Selenium and -compounds 10 Tellurium and -compounds 10 Thallium and -compounds 10 Organic Tin and -compounds 100 Tungsten and -compounds 100 Cyanides 10 Formaldehyde 100 PAHs (Polycyclic aromatic hydrocarbons) 10 PAHs, oxidized (Polycyclic aromatic hydrocarbons) 100 Phenol and phenolic compounds 100 Phthalate (All) 100 PFCs (Perfluorocarbons) (All) 10 Toluene 10 Xylenes 10 Epichlorohydrin (Monomer) 10 Responsible Manager: (Print name) Signature: Function: Date:
Supplier Number. [O] – Tbe Reporting Company’s identifier with the Licensing Body. This identifier will be assigned by MCPSI -IMRO during the licencing process.
Supplier Number. The supplier number will be the Vendor Code assigned by MLNA/MLMX to each Supplier location. The maximum length for the supplier number is five (5) characters.
