Internal notation:

S I C K AG

Vers.02 - November 2007

Request for issuing a new password

By FAX

Company name

Street

ZIP / City

Phone

Fax

Responsible

A new password for the device:

Type

Serial number

Device- Counter- No.

We ask for transmission of the password:

by phone,

phone no.:

..........................................

by fax,

fax no.:

..........................................

by e-mail,

e-mail address:

..........................................

We are aware that the device is part of safety equipment, that the password is used for the
configuration of the device and is therefore confidential and must be protected against
unauthorised access and use.
We also know that the complete safety system must be checked regarding its effectiveness
after each modification in the configuration.

............................................

......................................................................................

Place, date

Signature / Company stamp

*) Please use capital letters

SICK

FAX- No.

Hereby we request:*)

Please adapt the address
of your SICK subsidiary