Laser Device Disposal Form Laser Device Disposal Form Authorized User:* First Last Laser Safety Contact:* First Last Contact Phone Number:*Contact Email:* Laser Location Building and Room:* Laser Device InformationManufacturer:* Model:* Serial Number:* Laser Class:* Laser Type:* UW Invenotry Number:* Intended Laser Disposal MethodReturn to Laser Manufacturer* Yes No Contact Name: First Last Address Street Address Address Line 2 Estimated Date of Transfer: MM slash DD slash YYYY Listing at SWAP for Resale (AXMust be conducted in coordination with SWAP and ORS):* Yes No The bidding facility/institution should have laser safety program in place with active LSO. Laser should be in working condition. The laser cannot go for the public auctionDonation/ Transfer to Another Institution (Must be approved by ORS)* Yes No Donated/Transferred to: Date MM slash DD slash YYYY Disposal as Metal Scrap - Please follow these steps prior to disposal:* Yes No 1. Eliminate the possibility of activating the laser by removing all means by which it can be electrically activated. Remove the per cord and switches. 2. Remove any hazardous substances such as Mercury switches, Batteries, Dyes, Oils, Solvents, Biological, Chemicals, Radioactivity, etc., and wherever possible recycle them. 3. Remove and separately recycle any Laser Diodes or BeO Plasma Tubes from the Laser. 4. Must be examined by ORS and have a clearance sticker attached before disposing of as standard trash. Comments: I certify that above information is true and correct to the best of my knowledgeSignature:* Title:* Date:* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.