FIRE AND RESCUE DEPARTMENT UNDER THE MINISTRY OF THE INTERIOR Form: NKSD-126:16

FIRE RESEARCH CENTRE

PRODUCTS RESEARCH DIVISION

Miško str. 7, Valčiūnai vill., LT-13221 Vilnius distr. Ph. (+370 5) 249 13 13, ph./fax. (+370 5) 249 13 15

REQUEST FOR ASSESSMENT OF PERFORMANCE

reg. No.

(day) (month) (year) (filled in by FRC PRD)

1. We request to assess reaction to fire/resistance to external fire exposure of this product (products group):

Unique identification code of the product-type / Technical Regulation establishing the systems of assessment and verification of constancy of performance / Harmonised product standard regulating procedures of assessment of performance of product
Regulation (EU) No. 305/2011, Annex V, 1.4. System 3
and prepare:
Reaction to fire classification report in accordance with LST EN 13501-1 / and/or
Classification report for roof/roof coverings exposed to external fire in accordance with LST EN 13501-5
Write “X” in a window of the suitable option
Classification report hereby we request to prepare in / original exemplar (-s)
In this window write a number of exemplars

2. We take responsibility for:

*  for testing presenting typical products of intended or existing production;

*  correct grouping of products in the case of assessment of performance of product group;

*  paying tests and assessment of performance costs directed in contract;

*  providing all the information required for assessment of performance of product (products group);

*  ensuring future stability of assessed products and informing immediately Products Research Division of Fire Research Centre when manufacturer will change the design of a product.

3. Other information necessary for preparing of Contract:

Manufacturer
Address
Phone / E-mail
Company code / VAT code
Bank, Bank code, Account No.
Contact person, phone, e-mail
Payer*
Address*
Phone* / E-mail*
Company code* / VAT code*
Bank, Bank code, Account No.*

* - do not fill in if the Manufacturer is the Payer

4. We beg to enclose:

Document name / Number of pages
For example: technical data sheets, drawings, specifications, approved standard or the technical conditions according to which the plant manufacture products
Manufacturer Declaration (form NKSD-125:16) / 1

Note. Copies of documents notify with record „Copy is correct“, stamp and signature.

(Position, full name and signature of the company head or authorised person (with request approved authorisation to be submitted) entitled to sign the contract)

Request / submitted by:
Documents
Write “X” in a window of the suitable option / (position) / (full name) / (signed)
Request / accepted by:
Documents
(filled in by FRC PRD) / (position) / (full name) / (signed)
Test program No. / Specimens/samples delivering date:
(filled in by FRC PRD)
For tests we deliver:
(number of specimens/samples, dimensions)
Specimens delivered by:
(position) / (full name) / (signature)
Specimens accepted by:
(position) / (full name) / (signature)

Note: the highlighted part of the request to be filled on delivery of specimens/samples which are required for assessment of performance of product (products group)