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PRODUCT SUBMITTAL INFORMATION GATHERING FORM

COMPONENT – Printed Wiring Boards

Do you have a current UL File for this submittal?
/ YES / Please provide File, Volume, and Section Info and
Indicate any changes to Company Info, below.
If no changes are applicable, please only complete the fields on the right. / UL File #: / Volume, Section:
NO / Please complete the Company Information, below.
COMPANY INFORMATION
APPLICANT:The company or individual who applies to UL for the investigation of a component, product or system. This party contractually assumes the financial obligation for the cost of the investigation and Follow-Up Service, and thereby exercises the rights to information obtained as a result of the investigation.

COMPANY NAME:

STREET ADDRESS:
CITY, STATE:
PROVINCE, COUNTRY:
NAME OF CONTACT:
TITLE OF CONTACT:
TELEPHONE: /

FAX:

/

EMAIL:

MANUFACTURER:The company or individual who maintains and operates the factory facilities where a Listed, Classified or Recognized product is manufactured or assembled, and where the product is normally inspected and/or tested as a part of UL’s Follow-Up Service.
Mfr Info is same as Applicant Info / Mfr Info is same as Listee Info / New Manufacturer/ Location / Alternate Manufacturer/ Location
Company Name:
Subscriber Number:
Contact Personnel:
Please Provide Manufacturer Info
Please Provide any Additional Manufacturing Location Info on Separate Page if Subscriber # is Unavailable

COMPANY NAME:

STREET ADDRESS:
CITY, STATE:
PROVINCE, COUNTRY:
NAME OF CONTACT:
TITLE OF CONTACT:
TELEPHONE: /

FAX:

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EMAIL:

AGENT: A third party authorized to represent the Applicant in dealings with UL. Please note an agent must have an active Agency Authorization on file.
AGENCY NAME: / AGENCY CONTACT:
EMAIL: /

TELEPHONE:

PURCHCASE ORDER: /

FAX:

PROJECT SCOPE
SCOPE: /

Addition of new PWB Singlelayer and/or Multilayer type.

Addition of base materials.

Addition of coatings and/or hole plugging materials.

Upgrade parameters and/or process of existing PWB.

ADDITIONAL INFORMATION/
OTHER:
PRODUCT INFORMATION
Double Click the Applicable Worksheets Below that Pertain to Your Product Type

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Singlelayer
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Multilayer
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Singlelayer Metal Base
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Multilayer Metal Base

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Check if Used
/
Check if Used
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Check if Used
/
Check if Used
CONTACT AN ENGINEER

Name

/

Email

/

Phone

USA /

Deanna Dean

/ /

360-817-5607

Michael Nguyen (English)

/ /

408-754-6577

Greater China /

Wendy Ma (Chinese)

/ /

+86-512-6808-6400

Doris Wan (Chinese)

/ /

+86-512-6808-6400

HyunJoon Shin (Korean)

/ /

+822-2009-9342

JiHyun Kim (Korean)

/ /

+822-2009-9340

Masamichi Takagi (Japanese)

/ /

+81-3-5293-6280

Kazuki Mori (Japanese)

/ /

+81-596-24-7788

Europe /

Emma Hudson (English)

/ / +44-1483-40-20-37

Renata Segobia (Portuguese)

/ / +55-11-304-98707

Rita Chiodini (Italian)

/ / +39-039-641-0142

Wendy Stikvoort (Dutch)

/ / +31-26-376-4885

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