Appendix to Application for Conformity Assessment
Pursuant to Government Regulation117/2016 Coll.*) (hereinafter referred to as GR) (Directive2014/30/EU *))
ELECTROMAGNETIC COMPATIBILITY OF PRODUCTS

Please submit with your Application the following:

Technical documentation required for conformity assessment pursuant to Annex2 (3), or Annex3 (3c) to
GR 117/2016 Coll.

(Please mark with a cross the activities you wish to order)

1. The Customer hereby orders from the Notified Body the following activities:
1.1 / EU-type examination by reviewing the technical design of an apparatus pursuant to GR117/2016 Coll., Annex 3, Part A, relating to the following aspects of essential technical requirements pursuant to GR 117/2016 Coll.,Annex1:
1. Essential requirements
-Point a) / 1. Essential requirements
- Point b) / 2. Particular requirements for fixed installations and use of components for the given purpose
with issuance of an Evaluation report and issuance of EU-type examination certificate:
Language: / Czech / English / German / Other
(Note: For this activity, it is essential to submit the technical documentation – see GR 117/2016 Coll., Annex 3 (Part A) (3c))
2. The Customer hereby orders from the Engineering Test Institute, Public Enterprise, the following activities (Beyond the scope of the Notified Body's activities):
2.1 / Assessment of conformity of equipment to essential technical requirements of GR117/2016 Coll., and subsequent issuance of the Certificate attesting conformity of the tested sample to the essential requirements
2.2 / Assessment of conformity of equipment to essential technical requirements of GR117/2016 Coll., concluded with issuance of FinalReport
2.3 / Assessment of a set of technical documentation
2.4 / Assessment of measures in production to ensure conformity ofthe manufactured equipment based on internal production control pursuant to GR 117/2016 Coll., Annex 3, Part B
2.5 / Verification of conformity of electrical equipment to essential requirements of principal elements of the safety objectives under GR118/2016Coll. (2014/35/EU)
2.6 / Verification of conformity of electrical equipment to requirements of the standard
2.7 / Issuance of: / Certificate/s
Language: / Czech / English / German / Other
2.8 / Issuance of: / Final (summary) report / Evaluation report
Language: / Czech / English / German / Other
2.9 / Other(specify):
Appendix completed by:
Name and position of responsible person / Date / Signature, stamp

Should you need any help with completion of this form, please contact:Ing. Antonín Heitl (Brno)

Ing. Jiří Petr (Brno)