Electronics Manufacturing Hazardous Material Declaration Form

Company & Product Information

Company Name Contact Person Contact Email Product Name / Model Part Number

Hazardous Material Compliance

Does the product contain hazardous materials? Yes No

List of Hazardous Substances

Substance Name	CAS Number	Concentration (%)	Part / Material included	Regulation Reference

Additional Details

Applicable Regulations (e.g., RoHS, REACH, etc.) Handling/Disposal Instructions

Declaration & Signature

Name Title Date