Vojenský technický ústav, s.p., odštěpný závod VTÚPV Víta Nejedlého 691, 682 01 Vyškov, Czech Republic Company ID: 24272523 VAT No: CZ24272523 Head of Accredited Testing Laboratory No.1103: Ing. M. Bezděk [email protected] Business Dep.: Hana Vráblová [email protected] Electrical Safety: Ing. Z. Plch [email protected] EMC and Climatic Tests: Ing. P. Kupka [email protected] Vibrations and Noise: Ing. I. Štuchal [email protected] Vehicles: Ing. J. Zikmund [email protected] Certification: Ing. M. Bezděk [email protected] tel: +420 910 105 580 mob. +420 725 119 007 tel: +420 910 105 518 mob. +420 602 509 730 tel: +420 910 105 630 mob. +420 724 901 551 tel: +420 910 105 610 tel: +420 910 105 600 tel: tel: +420 910 105 580 mob. +420 603 705 329 mob. +420 603 701 582 mob. +420 604 744 661 mob. +420 725 119 007 GPS of Accredited Testing Laboratory No.1103, Vyškov: 49° 18´ 43,71´´ N a 16° 58´ 44,59´´ E www.vtusp.cz Warning: Vojenský technický ústav, s.p. is the compulsory subject for publication of contracts, in line with the Law No. 340/2015 Col., concerning the special conditions of effect of some contracts, publication of these contract and concerning the contracts register (Law concerning the contracts register), as it is the body mentioned in the § 2 par. 1 k) of the Law concerning the contracts register. Order No. (filled by VTÚPV) APPLICATION FORM: EMC (2014/30/EU and 2014/53/EU Directives) Electrical Safety (2014/35/EU Directive) Technical tests (climatic, vibrations, shocks, noise, vehicles, fuels…) mark only the requested tests 1. APPLICANT Trade name: Comp.ID: VAT No.: Tel.: Fax: E-mail: Place of business: Address: Person responsible for contract dealings: Tel.: E-mail: Person responsible for technical dealings: Tel.: E-mail: Tel.: E-mail: Tel.: E-mail: 2. MANUFACTURER (if different from the applicant) Trade name: Place of business: Name and address of the factory: 3. PRODUCT Accurate name: Type: Serial number: Technical documentation (number, name): (Please, send the technical documentation such as operating instructions, action statement, electric circuit diagram etc. with this application form at the same time.) 4. BASIC TECHNICAL DATA OF THE PRODUCT Power Supply: Input Voltage: Phase Current: Plug/Socket Type: R Dimensions (L x W x H): Weight: Name and Type of Used SW: Specification of Use: Product is intended for installation in vehicles: YES / NO Highest frequency used in the tested product: MHz Modes of operation in which the product will be tested: - Number of modes: - Names of modes: a) b) c) 5. TESTING PURPOSE (mark out by a cross): For conformity assessment 6. REQUESTED SCOPE OF TESTING: For the development Other reasons a) EMC - electromagnetic disturbance (mention the requested standards): b) EMC - electromagnetic immunity (mention the requested standards): c) Electrical safety (mention the requested standards): d) Technical tests (mention the requested standards): e) I ask for preparation of extent of testing (mark out by a cross) yes no 7. REQUESTED OUTPUTS: a) Measuring without Test Report (mark out by a cross) b) Test Report number of copies: yes Czech English German no Other (specify) If you require - conformity assessment (2014/30/EU Directive), - VTÚPV certificate (for confirmation of specific characteristics of the product) please, fill the Annex 1 of this Application Form and send it to M. Bezdek ([email protected], tel. +420 910 105 517). 8. Payment method: Credit transfer 9. Required date of testing: 10. Other requirements (describe): 11. This application form includes the annex consisting of sheets. ……………………. Date ………………………………. Applicant stamp .………………………………………..……………………… Name, position and signature of the responsible person 12. Application Form Reviewed: ……………………. Date .………………………………………………………………… Name, position and signature of the responsible person 13. Price of Examination: ………………………………………. 14. Date of performance: (if different from the requested date) …………………………………………. 15. Place of testing: …………………………………………. 16. Issue of Test Report: Within 10 working days after completion of the tests 17. Sending of Test Report: After the full payment of the invoice. 18. Invoice Due Date: …………………………………………. 19. Application Form Confirmation: ……………………. Date ………………………………. Supplier stamp ………………..…………………………………………….………… Name, position and signature of the responsible person Annex No. 1 Vojenský technický ústav, s.p.,

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