Request for Product Certificate/Registration/Licence Form* *Request for Technical Evaluation Report

GTS-PM-CAP-FRM-PRL-11 Page 1 of 3

RFI – For Intertek Use Only

IMPORTANT: The quality and completeness of the documentation submitted by the Applicant directly influences the time and cost of processing the certification request. This form must be completed in FULL. Applications will not be processed without all of the information completed. If more space is needed, additional sheets may be attached.

SERVICES REQUESTED

ALGERIA BOTSWANA EGYPT ETHIOPIA GABON

KENYA KSA KUWAIT NIGERIA QATAR

RUSSIA TANZANIA UGANDA OTHERS, (Please Specify):

APPLICANT TYPE

TRADER MANUFACTURER THIRD-PARTY LOGISTICS

AUTHORIZED DEALER AUTHORIZED DISTRIBUTOR OTHERS, (Please Specify):

PURPOSE OF APPLICATION NEW RENEWAL REVISION DUPLICATE CANCELLATION

REGISTRATION

LICENCE

PRODUCT CERTIFICATE 1 (UNREGISTERED STATUS)

PRODUCT CERTIFICATE 2 (REGISTERED STATUS)

PRODUCT CERTIFICATE 3 (LICENSED STATUS)

TECHNICAL EVALUATION REPORT

OTHERS, (Please Specify):

REGISTRANT / LICENCEE DETAILS

REGISTRATION NO. : LICENCE NO. : TER NO. :

PC-1 : PC-2 : PC-3 :

1

PAYMENT DETAILS RESPONSIBLE PARTY WHO WILL BE PAYING FOR THE SERVICES APPLICANT WILL RECEIVE

PAYMENT-IN-CHARGE: FREIGHT FORWARDER TRADER THIRD PARTY LOGISTICS

MANUFACTURER OTHERS, (Please Specify):

COMPANY NAME:

ADDRESS:

CONTACT PERSON: EMAIL:

TELEPHONE: FAX:

PAYMENT TYPE: CASH CREDIT INTERTEK CREDIT REFERENCE. NO. :

FEDERAL TAX ID / VAT NUMBER

ADDRESS WHERE INVOICE TO BE SENT CURRENCY TO BE USED FOR INVOICES

USD JPY GBP INR EUR

CNY OTHERS, (Please Specify):

MANUFACTURER / EXPORTER DETAILS

COMPANY NAME: FEDERAL TAX ID / VAT NUMBER

ADDRESS:

CONTACT PERSON: E-MAIL:

TELEPHONE: FAX:

DOCUMENTS ATTACHED TO THIS APPLICATION

VALID TEST REPORTS/TEST CERTIFICATES PRODUCT SPECIFICATION SHEET FACTORY INSPECTION REPORT

ISO/IEC 17025 CERTIFICATION PHOTOGRAPHS OF PRODUCTS PRODUCT IDENTIFICATION DECLARATION

QMS CERTIFICATES (e.g. ISO 9001, ISO 16949, ISO 22000…) SUPPLIERS DECLARATION OF CONFORMITY

VERIFIED MANUFACTURERS TESTING CERTIFICATE OTHERS, (Please Specify):

Request for Product Certificate/Registration/Licence Form* *Request for Technical Evaluation Report

GTS-PM-CAP-FRM-PRL-11 Page 2 of 3

REMARKS AND COMMENTS

DECLARATION

I/WE …………………………..……………………….… THE UNDERSIGNED, CONSENT TO INTERTEK’S TERMS AND CONDITIONS AND THE REQUIREMENTS STATED ON PAGE 3 HEREIN WHICH FORM AN INTEGRAL PART OF THIS APPLICATION. I/WE ALSO AGREE TO SHARE ANY OF THE DATA, RESULTS AND DOCUMENTATION GATHERED AND GENERATED DURING THE PERFORMANCE OF THIS SERVICE WITH THE CONCERNED AUTHORITIES.

NAME : SIGNATURE :

POSITION : DATE :

************************************************

SUBMISSION OF THIS APPLICATION CONFIRMS CONSENT TO THE TERMS SET OUT BELOW

1. This application for Conformity Assessment Programme (CAP) product certificate Registration and/or Licensing, together with the submittal of product test reports, and other related documentation, constitutes your request to Intertek to open a CAP compliance review for CAP Registration and/or Licensing project and review your products against standards approved by respective authorized bodies.

2. The purpose of the service is to provide a means for an applicant to identify that a Regulated Product complies with specific CAP Conformity Assessment Programme requirements by means of submission of technical evidence of compliance where necessary.

3. Intertek represents and warrants that any Certificate or Report issued in response to this application is issued in good faith and in the reasonable belief that it has authority to do so from the respective authorities or within the provisions of relevant decrees issued by them.

4. We commit to fulfill the certification requirements, including implementation of appropriate changes as and when advised by Intertek.

5. It is understood that, after reviewing and approving the content of this application and submitted documentation standards that the product(s) comply with, the Country Office/ Centre for Technical Expertise/ Registration and Licensing Centres (CO/CTE/RLC) will issue necessary Licence/Registration documents for the product(s) specified on this document. If the substantiating technical evidence is found to be incomplete, the CO/CTE/RLC therefore reserves the right to request such test data for evaluation or to enforce testing of the product(s) at any time during the validity of the certification document. Such activities are at the applicant’s or exporter’s expense.

6. We will allow Inspection Auditors and/or Observers from the Country Office to access our premises in order to perform further assessment and verification on the continuous compliance of Registered and Licensed products.

7. It is acknowledged that all fees quoted are estimated based upon information supplied to this office (CO/CTE/RLC).

8. We understand that Intertek, in performing its functions as requested by us, does not assume or undertake to discharge any responsibility of ours to any other party. It is recognised that the opinions and findings of Intertek, with regard to the request made by us, represent its judgment given after due consideration to the attendant limitations surrounding the circumstances and agree with Intertek that Intertek does not warrant or guarantee the correctness of its opinions, or that there will be universal agreement with, or acceptance of, such findings.

9. For evaluations and reviews performed at the applicant's request in a location, other than at a CAP Registration and Licensing Centre facility, it is understood that travel, maintenance, and miscellaneous expenses will be billed in addition to the testing fees, unless specifically included in the attached proposal.

10. We will keep a record of all complaints made known to us relating to compliance of Registered or Licensed products and will assist Intertek in the investigation and resolution of any complaints made by third parties.

11. If we provide copies of the Registration or Licence to other party, the document shall be reproduced in its entirety.

12. It is acknowledged that we will not use, nor refer to the Intertek name or logo on labels, product nameplates, brochures, advertising or sales promotion material which indicates or implies that a product is listed or approved by Intertek until written authorisation has been received by applicant for such use. The Registration or Licence issued is only for the products evaluated and verified by Intertek and must not be used in communication media and any marketing documents to indicate otherwise.

13. We understand and agree that Intertek reserves the right to share any of the data, results and documentation gathered during the performance of this service if requested, by the national standards body/authority implementing the Conformity Assessment Programme i.e. KSA MoCI, PAI, KEBS, SON, UNBS, AFNOR, TBS, BOBS, QGOSM,

14. Upon suspension, withdrawal, or termination of Registration or Licence, we shall discontinue the use of all advertising matter that contains any reference thereto and takes appropriate action as required by Intertek and takes any other required measures.

15. We shall inform Intertek, without delay, of any changes that may affect our ability to conform with the Registration/Licensing requirements.

16. It is understood that we have read Intertek’s Terms and Conditions. (If not, a copy is available from Intertek website http://www.intertek.com/government or upon request from your nearest Country Office).

17. We understand that the product(s) listed in this application will be subject to random programme specific consignment inspection/ certification procedure and intermittent testing prior to export.

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

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

GTS-PM-CAP-FRM-PRL-11 Page 3 of 3

NOTE: Applicant need not complete the below table with the requested information if the submitted invoice/shipment documents includes this information or if this is provided separately in an easily editable electronic

format (e.g. word, excel, rich text format document). If you need to provide more information than the available space permits, please attach EXTRA SHEETS using same format as below.

PRODUCT DETAILS

PRODUCT DESCRIPTION MODEL / TYPE / BATCH NO. BRAND COUNTRY OF

ORIGIN MANUFACTURER’S NAME

AND ADDRESS HS CODE* STANDARD REF.

ADDITIONAL INFORMATION PROVIDED ON SEPARATE SHEETS: YES NO. OF ADDITIONAL SHEETS NO

ACRONYMS USED USD – US Dollars GBP – Great British Pound JPY – Japan Yen INR – Indian Rupee EUR – Euro CNY - China Yuan Renminbi HS Code- Harmonized Commodity Description and Coding System QMS - Quality Management Systems PC – Product Certificate TER - Technical Evaluation Report