(supplier’s name)
(supplier's details - head office, reg. No., legal form of the legal entity, register in which data of the legal entity
are accumulated and kept, phone and fax numbers and e-mail or residence address,
personal ID number, phone and fax numbers and e-mail of the natural person)
To Conformity Assessment Division
of Fire Research Centre of Fire and Rescue Department under the Ministry of the Interior
(name of the certification body)

APPLICATION FOR CONFORMITY EVALUATION

No.
(date)

1. We hereby request to evaluate conformity of the following fire equipment and declare that: (mark the correct as indicated: x)

Fire equipment / Type / Conforms to (technical specification conformity to which is declared)
o Obligatory evaluation / o Voluntary evaluation
Manufacturer
Manufacturer’s address

Note. If needed, continue the list of the fire equipment submitted for conformity evaluation on an additional sheet.

2. We undertake:

- to pay a deposit of LTL ______for registration of the application;

- to cover all other costs related to conformity evaluation.

Note. The deposit for registration of the application shall not be subject to refund in case the head of the certification body takes the decision to cancel the application in the manner prescribed in the Rules of Conformity Evaluation for Fire and Rescue Machinery, Fire Safety Equipment and Fire Measures and Fire Automation Equipment.

3. Details of the supplier and the supplier’s representative:

VAT number
Bank / Bank number
Bank account
Supplier’s representative responsible for conformity evaluation / Name / Phone
Surname / Fax
e-mail

4. ENCLOSED:

Title of the document and number of pages (if any enclosed)
Regulatory document / o
Quality system certificates
(ISO 9000 series) / o
Certificates of conformity / o
Testing and production control system evaluation documents / o
Fire equipment manuals (instructions, etc.) / o
Other documents (drawings, diagrams, etc.) / o

Note. Authenticity of the copies must be confirmed.

(supplier’s or its representative’s position)* / (signature) / (full name)

* The title of the position is given, where the application is submitted by a legal entity.