/ CSA Group Testing UK Limited
Unit 6, Hawarden Ind. Est.,
Hawarden, Deeside,
CH5 3US, UK
/ Tel:
+44(0)1244670900
Email:
/ Website:
www.csagroupuk.org
ATEX/IECEx and CSA Product Certification Quotation Request Form
All information received is treated in strict confidence

Please complete all sections of this document. For help in completing this form please contact CSA Group on the details above.

What service do you require?

/
Enter 'X'
A new or existing product to be certified under the ATEX Directive
A new or existing product to be assessed under the IECEx Scheme or to be certified against IEC standards
Variation to existing Sira ATEX/IECEx certificate and/or upgrade of standards / Please use FORM 9124.
Contact us for a copy.

North American Assessment CSA approval – CSA Canadian approval

North American Assessment CSA approval – CSA U.S approval

Unit Verification under the ATEX Directive (CSA Group inspects each product manufactured)

Unit Verification under the IECEx Scheme (CSA Group inspects each product manufactured)

North American Field Certification – CSA Canadian approval (CSA Group inspects each product manufactured)

North American Field Certification – CSA U.S approval (CSA Group inspects each product manufactured)

Other international approval scheme – Please state country and/or CB scheme
Technical Information Service (Certification Support) – An agreed number of hours to identify potential certification issues and provide technical advice prior to assessment. Our team will contact you to discuss your requirements.
Date when certificate issue is required

1  Submitter Details

Applicant (Certificate Holder) / Manufacturing Location (if different)

Name of Contact

Position
Company Name
Address
Postcode/Zipcode
Country
Telephone Number
Email Address
VAT Number
CSA Master Contract Number (if applicable)
The responsibilities of the manufacturer apply to any person who assembles, packs, processes or labels ready-made products with a view to them
being placed on the Community market under their own name. Therefore, the responsibility for compliance rests with whosoever appears on
the product label as “the manufacturer” irrespective of whether this is the Original Equipment Manufacturer, assembler or labeller.

2  Product Details & Description (please answer all questions below)

Model/Types
What is the product designed to do?
What does the product comprise of (components, materials etc). If a range of products, please indicate details of range, e.g. number of items in range, specification differences, etc.
How is the product powered?
What are the external connections and how are they made?

3  Marking Details Required

Please list which standards (and edition of standard) the product is designed to comply with
e.g. IEC 60079-1:2014
CSA 22.2 No 157-92
IEC 61010-1
IEC 60950-1
CSA C22.2 No 61010-1-12
CSA C22.2 No 60950-1-07
List Methods of Protection and Certification Scheme the product is designed to comply with:
e.g. ATEX Directive II 1 G D Ex ia IIC T4
Class I Div 1 Groups B, C, D
Class II Zone 21 Ex tb IIIC Db
Ambient temperature range
(Standard is -20°C to +40 °C)
It is assumed that ambient pressure range is 0.8 bar to 1.1 bar / Please contact CSA Group if equipment is used outside this range (0.8 bar to 1.1 bar)
Ingress Protection (IP) code (if applicable)
Enclosure type rating/NEMA code (if applicable)
Any additional information:

4 Quality Management System, Surveillance of Manufacture

The designated certificate holder is obliged to obtain product Quality Assurance approval (manufacturing licence) with the relevant scope for the
manufacture of most ATEX and IECEx certified equipment.
What is your current status with regards to product Quality Assurance? / Delete below as appropriate and append a copy of your approval
I hold a valid ATEX QAN certificate, with relevant scope (e.g. protection concept) for this request / YES / NO / N/A
I hold a valid IECEx QAR certificate, with relevant scope (e.g. protection concept) for this request / YES / NO / N/A
I hold a CSA Master Contract number and the manufacturing location has received an Initial Factory Evaluation / YES / NO / N/A
I hold ISO 9001 Certification / YES / NO / N/A
I require a quotation for:
ATEX Quality Assurance Notification (QAN) or extension to / YES / NO / N/A
IECEx Quality Assessment Report (QAR) or extension to / YES / NO / N/A
An IECEx licence to use the IECEx mark / YES / NO / N/A
A CSA Initial Factory Evaluation / YES / NO / N/A
ISO 9001/ISO 14001/OHSAS 18001 Certification (please state which) / YES / NO / N/A

5. Documentation Required for Preparing a Quotation

Below is a list of recommended documentation (as applicable to your request) that should be forwarded to CSA Group as part of the request
Documentation marked as * is mandatory. A member of our Customers Services team will contact you if we require further information.
Certification drawing package (in pdf format)*
Copy of any QA Notification certificates, if any*
Completed checklists for the appropriate standards
Label drawing
A complete list of safety critical components and their appropriate certification
Equipment operating manual & maintenance instructions or extract demonstrating compliance with EHSR 1.0.6
Product Datasheets
Circuit diagram
Declaration of Conformity to any applicable Directives
Copies of certificates and variations of certified products incorporated into your product
Copies of any test reports supporting your application
Samples: Please do not send samples with a quotation request. Please note however for any product approval work where samples are requested by CSA Group, we have a maximum lifting capacity of 2 tonnes.If test samples are likely to be heavier than this please contact us prior to shipment.If you are sending samples from a Non-European country it is important that you adhere to appropriate HM Customs & Excise procedures.

6. Declarations

The applicant attests that a contract has not been placed with another Notified Body for the certification of the product listed herein (ATEX/IECEx).
If another Ex CB has been involved in the certification of this product, the applicant must make these details known to CSA Group.
The applicant accepts the rights to any certificate issued shall be vested in the name of the manufacturer stated in Part 1.
The applicant attests they are the authorised representative of the manufacturer stated in 1 & that evidence of authorisation be provided on request.
The applicant attests that unless stated otherwise no consultancy service has been involved in the design or modification of this product.
The applicant confirms that it is in full possession of all necessary rights on the product to be tested (including its components), insofar as testing and/or certification is applied for.
The applicant attests that the product and technical documentation provided that are the subject of this request are not regulated or restricted by local or international export or transfer regulations.
On acceptance of a CSA Group quotation, the client agrees to provide CSA Group with a signed formal acceptance and Purchase Order (P.O) number. Without a P.O number, CSA Group cannot start/progress the project.
The applicant accepts that a quotation will be provided by CSA Group Testing UK Limited, on behalf of Sira Certification Service (ATEX/IECEx).
Signature
Print Name / Date

For CSA approval:

In addition to the actual cost of establishing this certification, a separate annualmaintenance fee will be required. The maintenance fee is based on the factory location and is subject to our annual pricing increases.

The Annual fee has three components:

(a) An "Annual Licensing Fee” which covers the use of the CSA Mark on your products as well as maintenance of your records.

(b) An "Inspection Fee” x 4 visits required during the year.

(c) An "Annual surveillance” fee is a fixed cost for each factory.

Each new factory will be subject to an Initial Factory Evaluation fixed fee evaluation.

Page 1 of 2 Form 9118 Issue 30