Chemical Receipt Form
For RMS Use Only
Purchase Order #
Recipient Information
Name
Department
Email
Phone #
Chemical Information
Supplier / Manufacturer
Part #
Nomenclature
CAS Number
DEA/DHS
Acknowledgement and Signature
I, the undersigned, acknowledge that I have received the listed chemical and have read the Safety Data Sheet (SDS) and
will adhere to the policies & procedures in regard to the proper storage and handling of this chemical and disposal of
any waste connected to this chemical.
I have had an opportunity to clarify any questions, which I may have concerning any sections of the SDS.
Name (Print Name)
RMS-129 Chemical Receipt Form
Revised 11/20/2012
Signature
Date
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