F740042 Instructions - CVI Melles Griot

Melles Griot Laser Group
2051 Palomar Airport Road 200
Carlsbad California 92009
Tel 1-800-645-2737 (760) 438-2131
Fax (760) 438-5208
www.mellesgriot.com
How to Fill Out the Supplier Material Composition Declaration Form No. F740042
Introduction
Thank you for taking time to fill out the Melles Griot Supplier Material Composition Declaration Form.
Doing so will expedite the acknowledgement of compliance of your shipment in addition to allowing us to
identify your company’s product(s) as originating from a RoHS compliant supplier.
This instructional document is intended to accompany and to aide the completion of the Supplier Material
Composition Declaration Form No. F740042.
Requestor Information
Listed below is our contact information. Please send all correspondence to the address posted below.
Please acknowledge that we are the end users of your product(s) and carry the liability assuring that our
overall (manufactured) product is RoHS compliant to our clients. If you have any questions or concerns
in completing this form, please feel free to contact us. We will be happy to assist you.
Section A: Supplier Information
Melles Griot Laser Group
ATTN: Quality Assurance
2051 Palomar Airport Road, #200
Carlsbad, California 92011
760.438.2131
Company Name: Post your company’s business name and include any division if applicable.
Company Address: Post your company’s contact or business office’s mailing address. If you feel a need
to also disclose a manufacturer’s address, then please do so.
Contact Name: List a name or names of individuals that is/are knowledgeable representative(s) of your
product(s).
Phone: Post your company’s day time business telephone number.
Email: Post your company’s email address. If there is no email address, then post n/a.
F740042 Appendix A:1.1 Instructions to Supplier Material Composition Declaration

Melles Griot Laser Group
2051 Palomar Airport Road 200
Carlsbad California 92009
Tel 1-800-645-2737 (760) 438-2131
Fax (760) 438-5208
www.mellesgriot.com
Section B: Item Detail
In this section, please list all the items enclosed in your current shipment to Melles Griot Laser Group.
Feel free to copy Section C if additional space is needed.
Melles Griot Part Number: List the Melles Griot Laser Part Number(s). This is the number on the
purchase order and is on Melles Griot Laser’s referring documentation and order sheets. Please note,
that you may post as many part numbers as needed on the declaration form.
Supplier Part Number: List your company’s part number for the product(s).
Description: List a simple representational description.
Section C: RoHS Material Composition Declaration
Completion of this section is imperative. By signing this document you are declaring that your products
comply with Melles Griot Laser Group Specifications, posted on our website. Please review and refer to
all references to determine if your company’s products comply.
For your convenience, additional informative links are furnished on our website:
www.mellesgriot.com/lasersuppliers/
Declaration Statement (explanation):
Mark the appropriate box on the Declaration Form:
Material Analysis:
If your product(s) has / have undergone representational material analysis resulting in compliance
to all posted restrictions, then please mark box labeled Material Analysis and list method used.
Material Supplier Certificate of Conformance:
If your product(s) has / have Certificate(s) of Conformance satisfying the RoHS and Melles Griot
Laser Group Specifications, then please mark box labeled Material Supplier Certificate of
Conformance.
Signature:
Sign the document.
Date:
Date document with the date of signature.
Print Name:
Print name of individual who signed the document.
Title:
Post the title of the individual who signed the document.
Once again, thank you for completing this form.
Melles Griot Laser Group
F740042 Appendix A:1.1 Instructions to Supplier Material Composition Declaration