Request for Certification Form*

Request for Product Certificate/Registration/Licence Form* Request for Certificate of Conformity Form*

*Request for Technical Evaluation Report

*Request for Technical Inspection Report *Request for Certificate of Inspection

IMPORTANT: The quality and completeness of the documentation submitted by the Applicant directly influences the time and cost of processing the Registration/Licence request. The general Intertek Terms and Conditions and Additional Registration/Licence Conditions governing this application are embedded within this document for the applicant’s easy reference. Incomplete applications will not be processed.

REGISTRATION / LICENCE REQUEST FOR (Country Name)

PURPOSE OF APPLICATION NEW RENEWAL REVISION DUPLICATE CANCELLATION

APPLICANT’S DETAILS

COMPANY NAME

COMPANY ADDRESS

CONTACT PERSON E-MAIL ADDRESS

TELEPHONE NO. FAX NO.

FEDERAL TAX ID / VAT NUMBER

APPLICANT TYPE

MANUFACTURER DETAILS

If Manufacturer is different from the Applicant, Manufacturer’s details must be provided in the Exhibit A - List of Products table.

REGISTRANT / LICENCEE DETAILS (please provide, if available)

REGISTRATION NO.

LICENCE NO.

TER NO.

PC-1

PC-2

PC-3

DOCUMENTS ATTACHED TO THIS APPLICATION

Please also visit our website www.intertek.com/government to learn about the shipment certification services we can provide for the following countries such as Algeria, Bangladesh, Botswana, Ecuador, Egypt, Ethiopia, Gabon, G hana, Kenya, Kuwait, Libya, Mexico, Niger, Nigeria, The Philippines, Qatar, Russia, Saudi Arabia, Uganda. GTS-PM-CAP-FRM-PRL-16 Page 1 of 2 Request for Product Certificate/Registration/Licence Form* Request for Certificate of Conformity Form*

*Request for Technical Evaluation Report

*Request for Technical Inspection Report *Request for Certificate of Inspection

Please also visit our website www.intertek.com/government to learn about the shipment certification services we can provide for the following countries such as Algeria, Bangladesh, Botswana, Ecuador, Egypt, Ethiopia, Gabon, G hana, Kenya, Kuwait, Libya, Mexico, Niger, Nigeria, The Philippines, Qatar, Russia, Saudi Arabia, Uganda. GTS-PM-CAP-FRM-PRL-16 Page 2 of 2 Request for Product Certificate/Registration/Licence Form* Request for Certificate of Conformity Form*

*Request for Technical Evaluation Report

*Request for Technical Inspection Report *Request for Certificate of Inspection

PAYMENT DETAILS (Party responsible for paying the Registration/Licence service applied for, if different from the Applicant) COMPANY NAME

COMPANY ADDRESS

CONTACT PERSON E-MAIL ADDRESS

TELEPHONE NO. FAX NO.

INVOICE INTERTEK CREDIT PAYMENT TYPE CURRENCY REFERENCE NO. TO BE USED ADDRESS WHERE INVOICE IS TO BE SENT :

REMARKS AND COMMENTS (please provide, if any)

DECLARATION

I/WE CONSENT TO INTERTEK’S GENERAL TERMS AND CONDITIONS AND TO THE ADDITIONAL REGISTRATION/LICENCE CONDITIONS WHICH ARE ATTACHED HEREIN. I/WE ALSO ACKNOWLEDGE AND AGREE THAT INTERTEK MAY SHARE ANY OF THE DATA, RESULTS AND DOCUMENTATION GATHERED AND GENERATED DURING THE PERFORMANCE OF THE SERVICES TO THE EXTENT REQUESTED BY THE RELEVANT NATIONAL STANDARDS BODY AND OTHER AUTHORITIES TO VERIFY THE CONFORMITY OF THE PRODUCTS.

NAME POSITION DATE

Thank you for taking the time in filling out this form. We appreciate your business!

EXHIBITS

Note: Click on the above icons for accessing the embedded exhibits. List of Products using the template provided is to be completed ONLY if the product descriptions in the Invoice are not clear.