APPLICATION	concerning the performance of product certification, concerning the extension of the scope of the certificate, concerning the renewal of the certificate.
Application no.: KP/ /
Dear Sirs, please send us the below information to be used in preparation of our offer for product’s conformity assessment. Completion of the application does not mean an obligation to use our services, and no fee will be charged thereupon. Information contained in the application will be treated as confidential. Information on certification requirements as well as Applicants’ rights and responsibilities is available at website.

1.	General information (tick x as appropriate):
Applicant status:	manufacturer 1)	brand manufacturer 2)	authorised representative 3)
manufacturer - having detailed knowledge of the design and production process, is best placed to carry out the conformity assessment procedure. Conformity assessment should therefore remain solely the obligation of the manufacturer brand manufacturer - a particular group of manufacturers, a physical or legal person who sells a product under his name or trademark designed and/or manufactured by the actual manufacturer, identical in design and technology to the product introduced into the sales by the actual producer authorised representative - means any natural or legal person established within the Union who has received a written mandate from a manufacturer to act on his behalf in relation to specified tasks
Applicant:	Registered in (please specify register name and its location):
Adress:	Share capital:
Telephone:	VAT No.:
e-mail:

2.	Place(s) of manufacture (if different from point 1):
Manufacturer's name:	Registered in (please specify register name and its location):
Adress:	Share capital:
Telephone:	VAT No.:
e-mail:

3.	Product to be assessed for conformity with EU Directives or EU Regulations (please specify a name of the product – its proper name, the product type, etc., according to the product label. Given product name will be binding on each stage of the conformity assessment):
Name of product:
MED Directive	Modules:	B	D	E	F	G
PED Directive	Modules:	A2	B	C2	D	D1	E	E1	F	G	H1
PPE Regulation	Modules:	B	C2	D
List of standards and regulations applicable to the product:
Approvals, certificates held by Manufacturer:
Readiness for assessment:
Number of employees involved in certification process:
general:	in design:	In production:	In quality control:

4.	Additional Information
Have there been any complaints about products within the scope of the certificate during the validity period (refers to extension, renewal, renewal of the certificate)?	YES NO N/A
Does the Manufacturer have any connections (e.g. Business liaisons) with the provider of tests reports which are enclosed to this Application (if applicable)?	YES NO N/A

5.	Attachments to the Application (if applicable):	Notes:
Technical documentation of the product enabling conformity assessment performance according to the requirements of the directive/regulations and other applicable standards
Tests reports (if tests were performed)
Documentation of production quality assurance system
Risk analysis and assessment
Calculations
List of applied materials and components
Copy of the company registration document
Other documents
Samples of product with markings
Copy of the authorisation from the manufacturer to act on his behalf in relation to specified tasks (applies to Authorised Representative)
Copy of the partnership agreement between the manufacturer and the brand manufacturer (applies to Brand Manufacturer)

6.	Applicant’s declarations:
I undertake to comply with all requirements for applying for product certification/assessment of conformity. I undertake to supply complete technical documentation of the product and all information indispensable for assessment of the product. I confirm that an application for conformity assessment was not placed with another notified body. I confirm that the product presented for certification/assessment was not a subject of cooperation between the Applicant and EU-Cert LLC (e.g. at designing stage). I confirm that the product presented for certification/assessment of conformity is the same type of product as has been tested in the attached test report and that no significant changes/modifications have been made to the product (if applicable). I confirm that the modifications to the product made since the tests, the results of which have been provided, have had no significant effect on the performance of the product (if applicable).

7.	Applicant’s authorized contact person:
The Applicant shall familiarize the person authorized for contact with the Information Clause below.
Name and Surname:	Position:
Telephone:	e-mail:
Date:

PART FOR LEGAL ENTITY::

I agree to the use by EU-Cert LLC seated in Gdansk of telecommunications terminal equipment and automatic calling systems (e.g. telephone, e-mail), which we are a user of, for the purposes of direct marketing, in accordance with art. 172 of Telecommunications law and sending commercial information.

PART FOR NATURAL PERSONS (ALSO ONE-MAN BUSINESSES):

Information on the right to withdraw consent

You have the right to withdraw your consent to the processing of your personal data at any time. Withdrawal of consent will not affect the lawfulness of the processing which was carried out on the basis of your consent before its withdrawal.

Approval no 1 I agree to the processing of my personal data provided in this form by EU-Cert LLC seated in Gdansk for marketing purposes.

Approval no 2 I agree to the use by EU-Cert LLC seated in Gdańsk of automatic calling systems or telecommunications terminal equipment, which I am a user of, for the purposes of direct marketing, in accordance with art. 172 of Telecommunications law.

Approval no 3 I agree to receive business information by electronic means from EU-Cert LLC seated in Gdańsk, in accordance with art. 10 of the Act on the provision of electronic services.

Attachment no 1 Information Clause for natural persons (also one person companies) and also for persons authorized for contact indicated in p. 12 of this form