1 - SAI Global
1. Organisation information | |
|Details of applicant Manufacturing |Name |
|Organisation / Company Registered name | |
|(attach details of incorporation or | |
|other legal entity) | |
| |ABN & ACN (Australian applicants only) |
| |or company number (for example, ARBN) |
| | Company Partnership Sole Trader Other |
|Test station site address: |Street: |
| | |
| |Suburb |City |
| | | |
| |State |Country |Postcode |
| | | | |
|Organisation representative: |Name |
|(person who has the applicant’s | |
|authority in relation to the | |
|certification process and | |
|approval of invoices) | |
| |Position |
| | |
| |Telephone |Fax |Email |
| | | | |
|Mailing address: |Address |
|(for correspondence) | |
| |Suburb |City |
| | | |
| |State |Country |Postcode |
| | | | |
|Mailing address and contact |Name |Position |
|for Accounts Payable | | |
|(if different from above) | | |
| |Suburb |City |
| | | |
| |State |Country |Postcode |
| | | | |
|Distributor / Agent Organisation name | |
|Distributor / Agent Contact details |Name |
| | |
| |Position |
| | |
| |Telephone |Fax |Email |
| | | | |
|What are you applying for? (tick all | StandardsMark |Standard(s): |
|those applicable) | | |
| | ExMark |Standard(s): |
| | International eg. IECEX, EMC Mark Standard(s): |Standard(s): |
|2. Information about your company * |
|* Occupational Health & Safety Issues |
|Specify if visitors to your premises require personal protection equipment |
|(eg. goggles, hard hats or safety boots): |
|Information about your staff |Please provide information about the |Department |No. of Employees |
| |number of staff employed in each | | |
| |department. | | |
| |Note: This relates to those staff | | |
| |involved with manufacturing of | | |
| |product in respect of which | | |
| |certification is sought. | | |
| | |Manufacturing | |
| | |Design / R&D | |
| | |Laboratory | |
| | |Quality Control / Assurance | |
| | |Factory Total | |
|If some of these departments operate from a separate location, please provide details |
|Department name |Name |
| | |
| |Address |
| | |
| |Suburb |City |
| | | |
| |State |Country |Postcode |
| | | | |
|Other manufacturers |
|Please specify any other manufacturers / suppliers of critical components |
|Manufacturer’s name |Name |
|Please attach a separate sheet | |
|if required | |
| |Address |
| | |
| |Suburb |City |
| | | |
| |State |Country |Postcode |
| | | | |
|Type of component |
|Markets |
|Please identify your intended and existing markets for certified products |
|Intended and existing markets | Australia Domestic / Consumer Trade / Commercial |
| |Industrial Other |
| | International Specific region |
|Other types of certification |
|Does your company maintain other forms of certification eg ISO 9000, HACCP, ISO 14001 etc. |
|If so please identify the type of certification and certifying organisation. |
|3. Information about your product |
|Product subject to |Model No. |Model Name |Brand Name |Description |
|certification | | | | |
|(Include all models for which | | | | |
|certification is required) | | | | |
|Please attach a separate sheet | | | | |
|if required | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
|Other types of certification |
|Does your product maintain other forms of certification eg UL, NSF, TUV, BSi etc. |
|If so please identify the type of certification and certifying organisation. |
|4. Fees |
|Please refer to fee schedules for each scheme. |
|First application |$AUD | |
|Second and subsequent |$AUD | |
|applications | | |
|Total |$AUD | |
|5. Payment method |This application must be submitted together with payment of the applicable fee |
|Cheque |Cheques to be made payable to: | |
| |SAI GLOBAL LIMITED (ABN 67 050 611 642) | |
| |A cheque for $ is attached |Cheque No. |Date |
| | | | |
|Credit Card |Please charge (tick where applicable) |
| |Bankcard Visa Mastercard AmEx (ID No. ) Other |
| |Card No. |
| | |
| |Expiry Date |
| | |
| |Cardholder’s name (please print) |
| |Signature |
|Telegraphic Transfer |Bank National Australia Bank |THE REMITTANCE ADVICE SHOULD |
|Please make payment to: |Address 292 Pitt Street Branch |BE FAXED OR MAILED QUOTING: |
| |Sydney NSW 2000 Australia |ATT: Accounts Receivable - Fax (+612) 8206 6019 |
| |Acc name SAI Global Limited |Your company name: |
| |BSB Number 082-080 |Type of service and date: |
| |Acc Number 68 228 7431 |Invoice number being paid: |
| |Swift Number NATAAU3302S |Failure to advise details may result in delays in |
| |To ensure correct processing please include the |processing your payment. |
| |following information with your payment. | |
|Terms and Conditions |
|1 The applicant warrants that the information provided in this application| applicant; there is a contract for the supply of Certification or |
|form is correct. |Assessment Services upon the Terms and Conditions of Certification |
|2. The applicant acknowledges that it has received and agrees to abide by |Services, including the applicant’s obligation to pay all fees due in |
|the following contractual documents: |respect of the certification services, as calculated in accordance |
|(a) SAI Global Terms and Conditions of Certification Services (including |with either the Schedule of Fees or other agreement reached with SAI |
|the Schedule of Fees where applicable); |Global. |
|(b) Certification Procedures relevant to the Certification Services |4. The applicant agrees that if SAI Global issues a certificate and |
|requested (strike out if not applicable); and |licence to the applicant for the use of any Trade Marks (such as the |
|(c) Terms and Conditions of the Certification Mark Licence (where |StandardsMark), the applicant will use the Marks in accordance with |
|relevant). |the Certification Mark Licence Terms. |
|3. The applicant agrees that: |5. This application remains valid for 12 months from the date at which|
|(a) when SAI Global accepts this application in writing; or |the application was made, after which period the application will |
|(b) if the application is not accepted in writing, when SAI Global starts |expire. |
|to supply Certification or Assessment Services to the |6. All fees paid are non-refundable. |
|Signed for and on behalf |Signature of applicant or authorised officer of the applicant |Date |
|of applicant | | |
| |Full name (BLOCK LETTERS) |Title |
| | | |
|* Applicants may undergo a check on credit history through existing creditors and Credit Reporting Agencies. SAI Global reserves the right to |
|reject any application. **Attach additional pages as required. |
|Return completed application form with |The Administration Manager, Product Certification |
|payment to: |SAI Global Limited |
| |GPO Box 5420 |
| |Sydney NSW 2001 Australia |
| | | |
|Website sai- |Australia Phone: 1300 360 314 |Indonesia |
| |product@sai- |Jakarta Phone: (+6221) 720 6186 |
| |New Zealand Phone: 0800 761 995 |marketing.jakarta@sai-global.co.id |
| |info@sai-global.co.nz |Surabaya Phone: (+6231) 568 7155 |
| |India |marketing.surabaya@sai-global.co.id |
| |Bangalore Phone: (+9180) 555 9861 |North America Phone: 1-866-724-4562 |
| |sai_global.blr@ |and Mexico info@ |
| |Mumbai Phone: (+9122) 2659 1773 | |
| |sai_global.mum@ | |
|Your Privacy |
|SAI Global Limited and its related bodies corporate (“SAI Group”) respect stakeholders' privacy at all times. When processing your order or |
|application we collect personal information about you for the primary purpose of providing you with a high level of customer service. We may |
|also use this information to inform you of |
|other related products and services available from the SAI Group and to contact you in relation to these products and services. As we value your|
|privacy we do not make your personal information available to other organisations without your explicit consent, and you have the right to gain |
|access to this information. For more information please see our Privacy Policy on our website sai-. Please direct privacy related |
|enquiries to the Chief Privacy Officer on (02) 8206 6000 or by e-mail: privacyofficer@sai-. |
| |
|SAI Global office use only |
|Create new client Yes No |
|Other SAI GLOBAL program (e.g. CEM, OHS?) |
|Customer Number |
|App/Cert Number Standard |
|Preferred Auditor Client Manager |
|Technical Coordinator |
|Contract reviewed by |
|Date |
|Application Fee Due $ |
|Application Fees Received $ |
|Other fees Due $ |
|Total amount to be invoiced $ |
|Application Invoice Number QINV |
|Invoiced by |
|Date Application Received Date |
-----------------------
© Copyright SAI Global Limited 2005 All rights reserved ABN 67 050 611 642 PCF4806 CDAN05/6126 HMA109173
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