DROP BALL TEST CERTIFICATION
I _____________________________________ hereby guarantee that the articles
listed herein are impact resistant within the meaning of 21 CFR 801.410 and have been tested pursuant to that section. Impact resistant lenses are not unbreakable or shatterproof. Record of testing will be maintained for a period of three (3) years from the date of shipment and copies will be furnished to the FDA upon request.
Company Name: _____________________________________________________
Company Address: ___________________________________________________
City/State: __________________________________________________________
Country/Zip: ________________________________________________________
Authorized Name: ____________________________________________________
Authorized Signature: _________________________________________________
Title: ______________________________________________________________
Federal Express AWB#: _______________________________________________
Date: ______________________________________________________________