Accepted Test Facility

File Reference:

Accepted Test Facility

Relating to “Off-Site/Witness Testing” in accordance with IECExOD024

APPLICATION FORM

For acceptance of test results for the purposes of certification when

Ex product testing is conducted at manufacturer’s or user’s facility

PART A: APPLICANT INFORMATION
Name of Applicant Company*: / ABN:
(if applicable)
Phone No:
Address (Street): / Fax No:
City: / State: / Post Code:
Country:
Address (Postal): (If different from street address)
City: / State: / Post Code:
Country:
Authorised Contact Person: / Position:
Email Address of Authorised Contact Person:
PART B: TEST FACILITYSCOPE
Name ofTest Facility (If different to Applicant):
Address (Street):
City: / State: / Post Code:
Country:
Contact Person: / Tel. No.
Email Address of Authorised Contact Person:
Identify scope of testing for which approval is sought, and include relevant standard(s) and clause(s):
(If space insufficient, please attach details)
Part C: QUALITY MANAGEMENT SYSTEM INFORMATION
Identify quality accreditations/certifications held by the test facility
This will guide the extent of test facility assessment required
Quality Management System certification to ISO 9001:2008YES/NO
Laboratory accreditation to ISO/IEC 17025:2005YES/NO
Other quality accreditations held, provide detailsYES/NO
If YES, please enclose a copy of the certificate showing scope of certification

UNDERTAKING:

I/we confirm that I/we have read, understood, agree and undertake to abide by the Rules and Procedures of the IECEx System, including Operational Document IECEx OD 024 (Relating to Off-Site Testing and Witness Testing), as well as WorkCover / TestSafe’s General Terms and Conditions, as amended.

*We confirm that the Applicant Company in Part A of this application form is a manufacturer or end-user in the IECEx System and the applicant test facility is owned by the manufacturer/end-user.

We understand and accept that WorkCover / TestSafe or its appointed representative will conduct quality assessment of the test facility prior to approval for the scope of testing for which approval is sought, including follow-up assessment.

INVOICING:

I agree to pay all costs, as agreed by written quotation, incurred in carrying out the above work and will make payment, including upfront and progressive payments, in the timeframe stipulated by WorkCover / TestSafe, for such costs in accordance with WorkCover / TestSafe’s commercial forms.

Address for forwarding invoice:
Accounts payable contact: / (Name and email)
Phone: / Fax:

Signed for and on behalf of applicant:

(Signature of Authorized Person)*
(Name in BLOCK LETTERS)
Date: / (Title or position of Signatory)
(in the case of a Company, Firm, or Partnership)
* Person signing on behalf of test facility shall be an authorized company representative.
WorkCover NSW / TestSafe Australia ABN 77 682 742 966 919 Londonderry Road Londonderry NSW 2753 Australia
PO Box 592 Richmond NSW 2753 Australia Telephone +61 2 4724 4900 Facsimile +61 2 4724 4999
Email: Website:

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