DESTINATION MATERNITYCORPORATION

LAB TEST REQUEST FORM

PROTOCOL TESTING: Soft lines & Hard lines

Destination Maternity Corporation

456 North 5th Street

Philadelphia, PA19123

Phone (215) 873-2200 or Fax (215) 625-9812

Company Name: / Contact Person:
Address:
Report Copy via email to: MARI KOWALSKI
Telephone: / Failed Hard Copy report send to: MARI KOWALSKI
Fax: / Tech Designer:
Email address: / CC: /

Sample Description: / No. of Samples:
Style Number: / MWI Color #:
Manufacturer Name: / Fiber Content:
PO Number: / Country of Origin:
Testing Associate or Tech Designer: / Fabric Country of Origin:
Proposed Care Instruction:
End Use:
Dye Type:
Trim , Embellishment or heat seal:

Bureau Veritas : Service Required :

(Check One)

 Standard 5 Days

 Standard 10 Day

DESTINATION MATERNITY Protocol Testing Options:

(Check One)

DMAT Protocol: 0-999 – Soft lines (Baby apparel, Baby Blankets, Baby Articles etc.)

DMAT Protocol: 1000 – 1999 – Home Textiles

DMAT Protocol: 2000 – 2999 – Accessories, Bags, Diaper Bags, Luggage

DMAT Protocol: 6000 – 6499 – House wares & Food Products

 DMAT Protocol: 6500 – 6599 – House wares & Non Food Products

DMAT Protocol: 7000 – 7999 – Heath and Beauty Products

DMAT I Protocol: 8000 – 8499 – Toys and Baby Articles

DMAT Protocol: 9200 – 9399 – Footwear

DMAT Protocol: 9400 – 9599 - Candles

DMATProtocol: 9800 – 9999 Food Products

CPSIA General Conformity CertificateCPSIA Applicable rules review and GCC under BVCPS GCC services scope. Please provide name, full mailing address, e-mail address and telephone number of the person maintaining test records in support of the certification.

All Tests conforming with the Consumer Product Safety Improvement Act will require a Third party test report and Certification

Retest: / If yes, previous report number:
Other:

THIS TEST REQUEST IS SUBJECT TO THE CONDITIONS OF TESTING SET FORTH ON THE REVERSE SIDE HEREOF.

We request testing under the MOTHERS WORKTesting Program and agree that all testing will be carried out subject to the Motherswork Certified Labs scale of approved charges as set forth in the current price list for Bureau Veritas, ITS, Ekoteks, ICQ Global (Italy) and STR/Certintex (Peru) labs. Copies of Motherswork Test reports may not be requested by any other party other than the requesting vendor and Motherswork Inc. Motherswork test reports will be issued in locked PDF format to prevent tampering. Failure to comply with this requirement will result in de-certification of said lab.

Remark: Manufacture Information is required for CPSIA’s General Conformity Certificate

Name of Manufacturer:
Mailing Address / Tel No.:
Date of Manufacture (MM/DD/YY):
Place of Manufacture (City/Province/Country):
Date / Authorized Signature

Updated March 2007

Updated March 2007