/ VIPAC –CERTIFICATION SERVICES
GAS CERTIFICATION APPLICATION FORM
  1. Client (Certificate Holder) NoteDetails

Registered company name/legal entity applying for certification. / Company Name / ABN (Australian Company Only)
Physical Address
Mailing Address
Authorized Contact Details / Name
/ Company Position/Title
Phone No. / Fax No.
Website / E-mail
Note:Definition from The Vipac – Gas Certification Rules (hereafter referred to as ‘The Rules’).
Client: The legal entity applying for Vipac Product Certification and in Vipac Certification Services record systems also referred to as the Certificate Holder upon certificate issuance. The Certificate Holder is the legal entity responsible for compliance of the Product under the Terms and conditions of ‘The ‘Rules’.
  1. SupplierNote Details
/ SAME AS CLIENT
Details of the Supplier(company / legal entity), if different from Certificate Holder. / Company Name / ABN (Australian Company Only)
Physical Address
Contact Details / Name
/ Company Position/Title
Phone No. / E-mail
Note: Definition from‘The Rules’.
Supplier: The manufacturer in Australia or the importer of product into the Australian and New Zealand supply chain that will be held legally responsible for the certified product under the Terms and conditions of ‘The ‘Rules’. (i.e. those sellers located in Australia and New Zealand that are the first point of sale.)
  1. Manufacturer Details
/ SAME AS CLIENT
Details of the manufacturer (company / legal entity), if different from Certificate Holder. / Company Name / ABN (Australian Company Only)
Physical Address
Contact Details / Name / Company Position/Title
Phone No. / Email
  1. Quality Management System (QMS) – Declaration

QMS accredited to
ISO 9001 / Issuing Organisation / Certificate Number
Date of Certificate issue / Date of Certificate Expiry
Note Please attach a copy of your ISO 9001 Certificate.
QMS not accredited to
ISO 9001 / Do you have a formal customer complaints system? / YES / NO
Note Please provide your quality management system documentation including customer complaints system as a means of ensuring conformance of all released Product to the certification Standard.
/ VIPAC –CERTIFICATION SERVICES
GAS CERTIFICATION APPLICATION FORM
  1. Your Application Details

Application for a New Certificate / Application to modify an existing Vipac Certificate / Relevant Vipac Certificate Number:
Summary of modifications:
NotePlease attach a separate sheet if required / Separate sheet attached.
To your knowledge, have any of the Product/s you are seeking certification for, been rejected by a Conformity Assessment Body (CAB)? / YES / NO
If ‘Yes”, please provide details:
  1. Transfer of Certification to Vipac (if applicable)

Conformity Assessment Body (CAB) / Certificate Number / Status of
Certificate / Certified
Cancelled / Expired
Suspended
To your knowledge, are there outstanding matters with your existing certification that may contravene ‘The Rules’ / YES / NO
If ‘Yes”, please provide details:
Note Existing CAB must be JAS-ANZ and GTRC accredited. Provide details of product currently certified and intended to be listed with Vipac together with original or certified copies of issuing CAB certificate, last audit report, laboratory Type Test reports, instructions and specification and any other product related technical information, with this application form.
  1. Information About Your Product

Details of the appliances/components for certification / Product Type
Click to SelectDomestic and Commercial AppliancesCommercial Catering EquimentCamping and Leisure EquipmentComponentOthers (please explain) / Brand
Model
Description
NotePlease attach a separate sheet if required / Separate sheet attached.
Gas Types / Natural Gas / Propane / Universal LPG
Electrical Supply Data / Voltage (V): / Frequency (Hz): / Current(A):
Is the submission product a production sample or proto type? / Production / Prototype

Other types of certification

Does the product or its component parts have current certification(s) e.g. AGA, SAI Global, IAPMO, CE, CSA, BSI, DVGW, Gastec, TUV, etc?
If so please identify the type of certification and certifying agency:
Note Vipac at its discretion accept recognised local or overseas test report(s) as compliance with some relevant local Standards requirements, providing the assessments and report(s) are from a recognised source and the report and certificate are in English
Technical documentation required for certification
The following information is required to be forwarded with this application in order for initial processing to be completed.
New Product
Product description
Technical details
Draft instructions
Clearances to combustible construction / Modification to certified products
Specifications
Product drawings (assembly and discrete components)
Installation/operating/service instructions
Note For final processing all items listed in both columns will be required in addition to a final parts list (BOM).

Confidentiality

Vipac respects Client privacy, therefore any personal information we collect relating to you and your organisation is for the purpose of providing you and your organisation with a high level of customer service. This information shall be kept confidential other than information that you have consented to be released, is in the public domain or requested by Regulatory Authorities, Government bodies, the Courts, Tribunals and Police having interest in public safety.

/ VIPAC –CERTIFICATION SERVICES
GAS CERTIFICATION APPLICATION FORM
  1. Terms And Conditions

  1. The signatory warrants the information contained in the application is too their knowledge true and correct and, they are authorised to sign this application on behalf of the Client (proposed Certificate Holder) and the Supplier.
  2. The Client and Supplieracknowledge that they have read, and agree to abide by the following Vipac contractual documents.
(a)Fee Schedule. Detailed certification services quote available upon request, if not already provided,
(b)Vipac - Gas Certification Rules(‘The Rules’)– Scheme document CS1000,
  1. The applicant agrees that:
(a)When Vpac accepts this application in writing; or
(b)If the application is not accepted in writing when Vipac starts the certification process; there is an implied contract for the supply of services upon the terms and conditions detailed in the documents listed under clause 2 above.
  1. The Clientand Supplier accept the certification does not a guarantee product safety and furthermore the certification is based on a ‘Type Test’ regime of specific Product sample/s provided by the Client and assessed by Vipacto establish the product complies with the requirements of relevant Standards.The Certificate Holder and Supplierare the legal entities responsible for compliance of the Product.
  2. The Clientand Supplier attest they are responsible for:
(a)Maintaining a suitable quality management system,
(b)Ensuring Product conforms to the ‘Vipac – Gas Certification Rules’ and specifically the certification Standards, AS 3645 “Essential requirements for gas equipment”, including implementing appropriate changes when they are communicated by the certification body.
  1. Applications dormant (inactive) for a period of 12 months,may be terminated at Vipac’s discretion.
  2. Application/certification fees are non-refundable.
  3. Where additional time is required for revising ‘Type Test’ Program due to changes requested by the Client,optional inspection visit; or a Surveillance Inspection visit Vipacmay invoice the applicant for the expenses related to the undertaking.

Note: A copy of Vipac - Gas Certification Rules (‘The Rules’) is available on

The following signatory must be duly authorised and from the organisation to be named as the ‘Certificate Holder’

Full Name of Signatory (Please Print) / Company Position/Title / Signature
Company Name (Certificate Holder) / Date

The following signatory must be duly authorised and from the organisation named as the ‘Supplier’.

Full Name of Signatory (Please Print) / Company Position/Title / Signature
Company Name (Supplier) / Date

(Note: only required if the Certificate Holder and the Supplier are two different legal entities)

Please return completed and SIGNEDapplication form together with supporting product documentation to: or Shaun Shuaiwei Li:

CS1030-03 / Date of Issue: 17/01/2018 / Page 1 of 3