Application for a New Approval

and/or Modification of a Certificate

for an Electrical Product (Inc. EMC)

This form is to be completed in accordance with guidelines in Form S-0021 available at www.saaapprovals.com.au.

To Edit – Yellow boxes – Click to Check; Grey shaded areas - Click once to edit.

1. Application Details
Please select from the following application types:
New Certificate of Approval/Suitability:
Modification to Existing Certificate: Certificate Number:______
EMC Certificate and Compliance Declaration:
2. Applicant/Certificate Holders Details
Business name:
(name to appear on certificate)
Street address:
(to appear on certificate)
Postal address:
(if different to above)
ABN, ACN or IRDN:
(if applicable)
Contact name: / Title: Mr Ms Mrs Dr
Telephone/Mobile:
(include country/area code) / Ph: / Fax:
Mob:
Email:
3. Consultant Details
Business name:
Postal address:
(for all correspondence)
ABN, ACN or ARBN:
(if applicable)
Contact name: / Title: Mr Ms Mrs Dr
Telephone/Mobile:
(include country/area code) / Ph: / Fax:
Mob:
Email:
4. Product Details
Product description: / This field must be completed
Trade or brand name:
(to appear on product) / This field must be completed
Main model number/name:
(to appear on product) / This field must be completed
Electrical rating: / This field must be completed
Manufacturer’s name and address: / This field must be completed
5. General Modifications – General changes that affect one or more approved or to be approved models
6. Additional Models
Model Number / Difference between main model (4 above) or other recorded model. (attach list if insufficient space)
7. Test Report Details (Attach list if insufficient space)
Date of Report / Name of Laboratory / Test Report Number / Test Standard
8.a Declaration by Applicant (if form completed by applicant)
I have read and understood the SAA Approvals Terms, Conditions and Obligations (Form S-0110) and agree to abide by them.
I agree to pay SAA Approvals the relevant application fees and understand that the payment is non-refundable regardless of the outcome of this application.
I declare that the products submitted for certification are representative of a regular manufacture production line and that each product in that production line will be of the same construction as the product provided for compliance.
I declare that the product complies with the current relevant standard.
I acknowledge that any changes to the name and address of the certificate holder must be notified to SAA Approvals within one calendar month.
I acknowledge that any changes to a product approved under this application must be notified to SAA Approvals for assessment prior to the product reaching the market.
If applicable, I authorise the consultant, as per details in Section 3, to act on my behalf for this approval certification.
Authorised Signature: / Dated:
Name of Signatory and Title:
8.b Declaration by Authorised Consultant (if form completed by consultant)
I hereby make application to SAA Approvals for the certification of electrical products as described above in this application and declare that the statements and information provided in this application are true to the best of my knowledge.
I have provided the applicant with Form S-0110 SAA Approvals Terms, Conditions and Obligations and attached is a copy of the signed declaration stating that they have read, understood and will abide by them.
I declare that the applicant has provided written authority for my company to act on their behalf. Attached is a copy of this authority.
Authorised Signature: / Dated:
Name of Signatory and Title:
9. Payment Details (Please refer to our Schedule of Fees)
Cheque / Make cheque payable to – SAA Approvals Pty Ltd / Fee Amount: $
*PLEASE NOTE: Payments made by Amex will incur an additional charge (Refer to the Schedule of Fees)
Credit / *Amex / Visa / Bankcard / MasterCard / Verification Code:
(Last 3 digits on rear of card
or 4 digits on front of AMEX)
Account Number: / Expiry Date:
Card Holders Name:
(as shown on card)
Signature of cardholder: / Amount to debit credit card: $
EFT / For Reference: Use 1st 4 letters of applicant name and the model number (e.g. SAAA-1234) / Account details: Bank: Suncorp Metway Ltd, Cnr Turbot & Albert Sts, Brisbane, Australia. SWIFT CODE: METWAU4B
Acct Name: SAA Approvals Pty Ltd,
BSB: 484 799; Acct No: 084999851
(Please forward a remittance advice)

Mail: SAA Approvals Email:

PO Box 189, Cannon Hill QLD 4170 Australia Fax: +61 7 3393 9499