Company Information

Company Name:

Address:

Contact Person: Title:

Phone Number: Fax Number:

Email:

Website:

Manufacturer Information

Same as above

Manufacturer Name:

Address:

Contact Person: Title:

Phone Number: Fax Number:

Email:

Website:

Equipment Under Test (EUT) Description

Model Designation:

EUT Description:

Intended Use:

Intended Locations:

Available Options:

Configurations to be Tested:

Electrical Rating: Vac/dc: Hz:

Amps: Dimensions: Weight:

Table Top Floor Standing Rack-Mounted

Objective of Testing

EMC
United States (FCC)
Canada (ICES)
European Union (CE Mark)
Taiwan (BSMI)
Japan (VCCI)
Other:

Safety Standards (if Known)
UL (US)
UL (Canada)
CSA (US)
CSA (Canada)
TUV Rheinland (US)
TUV Rheinland (Canada)
TUV Rheinland GS Mark
TUV Rheinland CB Report
TUV America (US)
TUV America (Canada)
TUV America GS Mark
LVD Report (CE Mark)
Machine Directive Report (CE Mark)
Other

Support Equipment to be Used During Testing

Equipment: Manufacturer: Model/ Part #:
Equipment: Manufacturer: Model/ Part #:
Equipment: Manufacturer: Model/ Part #:
Equipment: Manufacturer: Model/ Part #:
Equipment: Manufacturer: Model/ Part #:
Equipment: Manufacturer: Model/ Part #:

Interconnecting Cables to be used during Testing

Cable Type: Cable Length: Shielded Yes No
Cable Type: Cable Length: Shielded Yes No
Cable Type: Cable Length: Shielded Yes No
Cable Type: Cable Length: Shielded Yes No
Cable Type: Cable Length: Shielded Yes No

Please list all know fundamental frequencies (if requesting EMC testing):

Is the product an intentional radiator? Yes No

Is the product for home use? Yes (Class B) No (Class A)

Additional Information:
Please Provide us with any additional information regarding your request in the field below.

Requestor Name (to act as electronic signature): Date: