Application for Evaluation of Products for QPS Field Certification

Contact:
Bill Stephenson CET
QPS
9410-95 Street Edmonton, AB Canada
T6C 3X3

phone number: 780 905-9601
fax number: 780 452-2813

E-mail address: bstephenson@QPS.ca

Please Fill Out ALL Information Completely Before We Can E-MAIL THE APPROPRIATE APPLICATION PACKAGE TO YOU

o For START-UP accounts, payment in full is required PRIOR to work done.

o Invoices must be paid within 30 days after the Evaluation for existing accounts

o QPS reserves the right to levy a 2% service charge for overdue accounts.

o The buyer will incur all shipping costs- Products are to be sent “free domicile”

o If this is a re-inspection of an existing device, then we will require the previous label log sheets

GENERAL INFORMATION:

ACCOUNTS PAYABLE, E-mail Address- :

Company Name:

Your Company Contact Name for Certification:

Phone Number:

Full Billing Address:

Postal Code:

Your CERTIFICATION CONTACT E-mail Address- :

Fax Number:

* Purchase Order (if for a quote write “QUOTE ONLY”):

Reference Number OR COMMENT (optional):

Number of Units, (OR LABELS REQUIRED), (FOR A PLANNED PRODUCTION RUN OF UP TO SIX MONTHS- THIS MUST BE FILLED IN, -LABELS ARE $2.50 EACH):

PREFERRED COURIER AND ACCOUNT NUMBER- IF YOU WANT YOUR PRODUCT SHIPPED BACK, OR LABELS SHIPPED- BEST TO FILL THIS IN

INFORMATION ABOUT THE EQUIPMENT YOU WANT CERTIFIED

(ALL OF THE FIELDS MUST BE FILLED IN):

Type of Unit[s]
Very Basic Description-(In five or six words):

Manufacturer of the equipment to be certified

(The MFG can be considered as the place where the labels are applied)

Manufacturer Contact:

Manufacturer address:

Manufacturer phone:

Manufacturer fax:

Model (Part# ) Number of the unit:
(do not put in the serial number):

FULL Electrical Ratings
120v/24v – 10AMP/ 3AMP etc:

Hazardous Designation you require
div1, div2, exproof, intrinsically safe or general purpose or

medical risk class, NEMA class etc…:

Location Of Inspection:

(If the same AS the APPLICANT or MFG then PLEASE STATE (“SAME AS MFG” or “SAME AS APPLICANT”)

(IF YOU ARE SHIPPING THE UNIT TO US, PLEASE STATE “QPS”)

Company Name:

Contact Name:

Phone Number:

Location Address:

Component Listings:

(DUE TO THE INCREASED VOLUME IN APPLICATIONS- THIS SECTION IS MANDATORY FOR ALL THE CERTIFIED COMPONENTS)

Designation (i.e. CLASS I DIV 2 CD T3 or general purpose)	Manufacturer Of the component	Mfg P/N	Technical Description (i.e. DIN mounted relay)	Electrical Ratings (Include volts and amps)	Certification mark (i.e. CSA/UL etc.)
I Agree With The Above: I Disagree With The Above:

MANDATORY FACTORY TESTS:

IF THE EQUIPMENT BEING CERTIFIED CONTAINS A VOLTAGE HIGHER THAN 32VOLTS, THEN A MANDETORY DELECTRIC TEST IS REQUIRED FOR EVERY UNIT. ----PLEASE FILL IN THE DETAILS OF THE TESTING EQUIPMENT THAT YOU WILL BE USING TO PERFORM THESE TESTS ON THE CERTIFIED PRODUCT (if the equipment to be certified is less than 32volts- please type in N/A)

DIELECTRIC TESTER -MFG:

DIELECTRIC TESTER- MODEL #:

DIELECTRIC TESTER- SERIAL NUMBER:

DIELECTRIC TESTER - DATE OF CALIBRATION:

FACTORY INSPECTIONS

If you have more than one model number certified with us- please type in all the models you wish to have included with this application. Please keep in mind that this will not affect the quote (It is advantageous to put as many as possible) New labels are not issued for these models at this time, however, it will reduce the cost and number of future factory inspections.(we will also require the previous factory logs for this as well)

Model numbers (simply separate the model # with a comma)

Save as a text file immediately after pressing the “Send Your Application” button—this can be used again for future applications by simply emailing us the updated text file.

OFFICE USE ONLY:

FILE NUMBER:

LABEL FROM:

LABEL TO:

STANDARDS:

STANDARDS:

QUOTE ESTIMATE:

COUNTRY:

CONNECTION TYPE: