<p> 10 Portman Road Reading, RG30 1EA, UK T: 0118 939 8700 F: 0118 939 8701 W: ul.com/consumer-products Email: [email protected]</p><p>For Office Use Only Sample Submission Date sample received: Laboratory number: Customer Details Company name: Address: Invoice address (if different):</p><p>Tel no: Fax no: Email address: Contact name for certificate: Product Details Product name for certificate: Order number: Product reference for certificate: Results required by: Tests required: </p><p>NOTE: Testing will be carried out to the current published version of the standard at the date of testing, unless stated otherwise. When textile testing is required, whenever possible this will be subcontracted to a UL Consumer Products laboratory. Where necessary, work subcontracted will be carried out by UKAS or UL Consumer Products approved laboratories. Any other information: </p><p>Do you require emailed or faxed Emailed (please ensure email address is shown above) confirmation of receipt of samples? Faxed (please ensure fax no is shown above) (please tick) Not required</p><p>Signature (full signature required) Date: </p><p>All samples tested by UL Consumer Products or subcontracted to UKAS/UL Consumer Products approved companies are accepted subject to agreement to our terms and conditions.</p><p>UL Consumer Products Sample Submission Jan 2013</p>