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       |

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© Copyright SAI Global Limited 2005 All rights reserved ABN 67 050 611 642 PCF4806 CDAN05/6126 HMA109173

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