This Form Is Identified by Its Number QMA-ASL-08-320 and Date 2013-09-10

Certification of explosion-protected electrical equipment
APPLICATION FOR Ex CERTIFICATION
Certificate of Conformity: / IECEx / ANZEx / ATEX Restricted Type
Test Report / Audit
New application
Change to existing Certificate / State existing Certificate Number:
PART A (Applicant information – invoices to be sent here):
Name of applicant: ......
ABN, if applicable………………………………….
Street address:......
...... / City:......
......
State/Province: ...... / Country......
Postal code: ......
Postal address:......
Contact person:...... / Position:......
Telephone:...... / Email :...... / .
Name of certificate holder (manufacturer): ......
If certificate holder is different from the applicant, please complete below:...... N/A: .
Name & Address of manufacturing location (if different to above):......
......
……………………………………………………………………………………………………………………………………….
- Indicate relationships/products/subassemblies of each site:......
......
……………………………………………………………………………………………………………………………………………….
Email the completed application form to:
TUV Rheinland Australia Pty Ltd
1/30 Kennington Drive
Tomago NSW 2322 Australia
Telephone +61 2 4964 5800
Fax + 61 2 4964 5899

This form is identified by its number QMA-ASL-08-320 and date 2013-09-10

PART B (Product information and Certificates of Conformity):
1.CERTIFICATES OF CONFORMITY. Identify any Certificate of Conformity already held for the product or product series. (If first Certificate of Conformity required, go to 2.)
2.DESCRIPTION OF EQUIPMENT. This will become the title of your Test Report and Certificate of Conformity. Include details of any modification for Supplementary certification.
3.TYPE OF PROTECTION / IP RATING
 d /  e /  ia
 Ib
 ic
 [ia]
 [Ib] /  ma
 mb
 mc /  nA
 nC
 nL
 nR /  o /  px
 py
 pz /  q /  sa
 sb
 sc /  ta
 tb
 tc /  Safe Area / IP / As tested
4.EQUIPMENT GROUP
I / IIA / IIB / IIC / IIIA / IIIB / IIIC
5.TEMPERATURE RATING
Group I / Group II / Group III / Ex tD / As tested
 150°C /  T1 /  T2 /  T3 / T………°C
 450°C /  T4 /  T5 /  T6
6,AMBIENT / SERVICE TEMPERATURE RANGE
MINIMUM / MAXIMUM / (DEFAULT) 20°C/+40°C / AS TESTED
7.STANDARD(S)
8.LIST OF DRAWINGS (Please attached extra pages if required)
9.ExTL COMMISSIONED TO CARRY OUT TEST (if other than TUV Rheinland Australia Pty Ltd).
N/A:  or:
PART C (Quality Management System information):
Does the manufacturer have a Quality Management System complying with ISO 9001:2008?
Yes / No
If yes, state the name of the third-party certification body and enclose a copy of the certificate showing scope of certification:
Original manufacturer:…………………………………………………………………………………………………………………………
Alternative manufacturer:…………………………………………………………………………………………………………………………
PART D (Samples)
All samples must be delivered to the TUV testing premises by courier or suitable transport, and adequately identified by Job Number.
Samples may be damaged or destroyed during the testing process, and the applicant warrants that such damage will be accepted without reimbursement to the applicant.
After the tests are completed and the final report and certificate have been delivered to the applicant / manufacturer, the client shall make suitable arrangements to have the samples returned to them.
The nominated courier / transport with account number is provided below, and all expenses shall be payable by the applicant
Name of courier / transport: ………………………………………………………………………………………………………………………
Your account name: ………………………………………………………………………………………………………………………………….
Your account number: ………………………………………………………………………………………………………………………………
UNDERTAKING:
I/we confirm that I/we have read, understood, agree and undertake to abide by the Rules and Procedures of the ANZEx Scheme, as outlined in Publication MP 87, the IECEx System as outlined in IECEx 02 and TUV Rheinland Australia Pty Ltd terms and conditions Specified in General Terms & Condition and Testing and Certification Regulations which forms part of our Service Agreement; that the manufacturer shall be bound by these rules and procedure; that the manufacturer has complete intellectual rights over the design submitted, and confirm that the product now submitted for Certification was designed to comply with the requirements of the Standards outlined in Part B.
Signed for and on behalf of Applicant: ………………………………………………………………………
Signature of Authorized Person*......
Name in BLOCK LETTERS......
......
Title or position of Signatory
(in the case of a Company, Firm, or Partnership)
Date......
* Person signing on behalf of the Applicant shall be an authorized company representative. If application is lodged by a person not directly employed by the intended Certificate holder (manufacturer), then a letter from the intended Certificate holder shall be attached.

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