APPLICATION FOR TESTING AND CERTIFICATION (fill in where relevant)

(1)

APPLICATION FOR TESTING

AND CERTIFICATION (fill in where relevant)

Intertek Semko quotation No. (if any):

Your P.O. No.:

1 APPLICANT

(for whom the testing/certification is requested)

Full name of company VAT No.

Applicant’s reference or contact name Intertek Semko client No.

Address Telephone

Telefax

E-mail address

2 REPRESENTATIVE

(if any, for

the applicant or for

the manufacturer)

Representative’s reference or contact name Intertek Semko client No.

Address Telephone

Telefax

E-mail address

3 MANUFACTURER

(if other than the applicant)

Manufacturer’s reference or contact name Intertek Semko client No.

Address Telephone

Telefax

E-mail address

4 FACTORY

LOCATION(s)

(if other than under item 3)

Full name of company

_{VAT No.}

_---

Factory’s reference or contact name Intertek Semko client No.

Address Telephone

Telefax

E-mail address

(2)

5 PRODUCT

Product category

Type designation/Model No.

Trademark (s)

Ratings/Technical data

Use additional sheet if necessary

6 STANDARD(s)

The product is designed to comply with the following standard(s). (Fill in issuing organisation, number, edition/year, any amendment)

7 SERVICE

REQUESTED

You are welcome to specify in which countries you intend to sell your product. We will than be able to inform you of what is required for your product in these countries. In addition specify if you want Intertek Semko’s help to have your product certified in those countries.

_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Safety

testing

Test report requested

Certification

for S marking, License

without the yearly licence fee but with an increased type approval fee

for GS marking ITS Testing & Certification GmbH

according to the Nordic Certification Services (NCS),

according to the Nordic Total Services

according to the CCA-CENELEC Certification Agreement  according to the CCA accelerated pr.

for the ENEC mark

for the Keymark

for a CB certificate  for a CB-FCS certificate

for a LOVAG certificate

for North America,

ETLus Mark (US)

cETL Mark (Canada)

CSA mark

for Eastern Europe,

Russia

Poland

other________

for Australia

for other ...

(3)

Certification for

S marking

GS marking

Nordic Certification Service (DK FI NO)

based upon

CCA certificate

CCA STC/STR

CB certificate

other________ Test report identity declaration to be enclosed. In some cases samples are necessary.

Special national conditions, if any, for SE DK FI NO and special requirement, if any, for

GS marking are included.

EMC

testing

Testing of

EMC emission

EMC immunity according to specification enclosed

TCF (Technical Construction File)

Radio and telecommunication testing

Testing of telecommunications equipment according to specification enclosed

Testing of radio equipment according to specification enclosed

EC

directives

Testing for verification of compliance with

LVD

MD

EMCD

MDD

R&TTED

other

CE marking package

Storage of technical file

Environmental

tests

Testing of energy efficiency according to

EC requirements

other requirements________

Testing for the Nordic Ecolabel, the Swan

Testing for the EC Ecolabel, the Lily

Measurement of magnetic and electrostatic fields

Other

Testing of enclosures according to the IP system, IP ....

Light distribution measurements

(4)

8 EXTENT

OF

TESTING

Complete testing of a new product

Variant (new type designation) 1,2)

Retesting 1,2)

Testing because the certification has expired

Alternative or changed design 1,2)

Other (specify)

1. Give Intertek SEMKO’s reference number of basic type if you want reduction of the testing fee.

2. Specify, under section (9) below, differences from the basic type previously tested/certified.

Intertek SEMKO’s order/reference No. of basic type

9 DIFFERENCES FROM THE BASIC TYPE PREVIOUSLY TESTED/CERTIFIED

Specify the differences from the basic type previously tested/certified

10 CERTIFICATION OF A COMPONENT (for use in the client’s own electrical products)

Component Manufacture Test data

11 PRODUCTION

CONTROL

Submitted earlier Enclosed Not available

Completed CIG 022B

(5)

12 THE FOLLOWING IS SUBMITTED

Number Encl. Separately Later Expected date of submission

Sample

Circuit diagram

List of components

Drawing showing location of components (mandatory if the product contains electronics)

Extra components (according to list enclosed)

Manual-

operating

installation

mounting Language

SE

GB

DE

other___ For GS marking a German manual is required

Names and addresses of repr. in other Nordic countries, if any

Certification of flammability class of printed boards (UL, BSI)

CCA NTR/STC/STR

CB certificate

Test report

CCA

CB

other____

Identity declaration

Photos of the product

Specification of EMC testing

Specification of testing at Intertek Semko Teletest

Information about Internal Production Control

13 RETURN/SCRAPPING OF TEST SAMPLE

Intertek Semko is to scrap the sample free of charge

Sample is to be returned after testing, freight charges to be paid by client

Sample will be picked up within one month after receipt of certificate/statement

14 SIGNATURE

We have obtained, read and understood Intertek Semko’s Agreement on Testing and/or Agreement on Certification.

In those cases where the application also covers the Intertek GS-mark, we have obtained, read and understood the general business conditions for Intertek Deutschland GmbH.

We confirm that we are aware that any offer, sampling of or trade in products with the certification mark before a mark’s license has been granted, are regarded as a deliberate and unlawful use of the certification mark. The conditions of the agreement(s) are accepted by this signature.

APPLICATION FOR TESTING AND CERTIFICATION (fill in where relevant)