適合性同等検査申込書（様式第四）別紙
Contents
1. CH Oo D oO qd D 4 CO Dr o o qa Bey t E CH coa o za a 4 O g o o oo mo o D d o0 o za a 4 O go o o CO mo o oO o a oO 52 E m O go CI ji oo o CO o oO EH o a D 52 E E Ek E oOo CO D o nn cu o 52 E pees ES E 6 CO D 0 oo no o a CH o o Og ope 2 g Oo qa oo o oO CO oo Oo o a An o SS Fale 01 E oer oo CO D D oo COD CH o CH E CH o0 o 4 o Da o 2 D o o o o o0 2 0 oo CIE co o0 o Ho o Og a o o oo oO 2 x0 oor g o0 o Hpo o oo oo oOo o Glo any E Oo q 0 E o OF O o o o 2 2_ o o o oo o Oo Ooo o oo o Po ca H ei oo o o oo o o Hua no o o0 o Po c O ao Ses oO o oo o o OOo no o i A ee E o oo o o o0oqa EE o o0 o Ho o Op Zo o o oo o o oono m o OF o On o o GUL EA ooo Soon 5 any CH o OH EH Ce Re ee Ve CC ooo ooo2. 0 7 0 70 0 8 1 0 71 4 7 0 4 U TEL FAX E mail TEL FAX E mail 20140401 PSE RE 403 Project No INFORMATION FOR INTERACTION Contact information for this application is as follows Please tick the appropriate box 1 JETS inquiries about this application are to be addressed to CI Responsible person for the application CI Agent as specified in Annex to the application O Point of Contact No below The Statement of Conformity Assessment and Test Report are to be sent to CI Responsible person for the application CI Agent as specified in Annex to the application O Point of Contact No below The testing fee and other expenses are to be borne by CI Responsible person for the application CI Agent as specified in Annex to the application O Point of Contact No below If the bill for the fee and expenses is to be sent not to the same one as above The bill is to be sent to CI Responsible person for the application CI Agent as specified in Annex to the application O Point of Contact No below What to do with the products after testing Please tick the appropriate boxes CI The tested products are to be sent freight collect to CI Responsible person for
3. Po ot S225 Ho go Ha oO oO ooo o00 0 ono d oF EE o Up ga CC ooo ooo E oo oc oo H o OO EI E 2o00 ono a Oo go o ooo CH Er oo oO Er g2 oO mili ooo g mt no Po ot Re ae o oo ooo mon oO Er oo oO Er nooo El oo ooo g oaa a o0 5 0 qu o200pn o D Pana m QUO OOo Ona oo E ET oO E CD o El Se ZE Boo o a o oo GS ooo 2o03 Og oo ooo 2o00 5 2590005 Oo oo oon 3 0005 Og EE ooo 2590005 o qu aa qan o pa 0 3 5 o00p e 0 o qu jar oan oOq00 Foo 0 8 o00p 20045 gt Oo oo D lt 0 0 Boor o po DIE 006 0 ooo 0 5 0 0 00 53 0 ooo O22005 o oo oaoa lt gt gt 00042 copo ooo gt gt gt 0 20045 0 0 6 0 00 Op00p 22045 0 copo mono 0 000242 0 0 0000p 20046 Soleo 0 nooo 0 0 400 Ooo 3 0 2004 0 e a S a 1 5 nooo 0 0 Ooo FO D02000 O000p 2004 E ooo DEE 0 0 0 Oooo 00 oe Ee
4. O JET n o 10 gt popgodo0000000000 HUUUUUDUUUI 000 1 1 0 0 000 H 000 L 20140401 PSE RE 402 Project No LIST of FACTORX S 1 Is the factory for this application the same as for the previous Statement Please tick the appropriate box O Yes gt Please fill in the number of the relevant Statement below It is not necessary to specify the factory here Statement Number JET O No Please proceed to 2 2 Please specify all factory s relevant to the application If they are more than four please specify them on the additional sheet s Factory 1 Name of factory Address of factory Factory 2 Name of factory Address of factory Factory 3 Name of factory Address of factory Factory 4 Name of factory Address of factory 20140401 PSE RE 403 0 00000000 0 00 000 1 0000000000 0 1 70 0 0 73 0 0 000 0 0d 0000000000000 1 0 0 000 Oo 0 0 0 730 0 0 ic 000 1 0 1 0 730 0 0 000 ceda
5. ULULU 8788 0 000 00 PSE RE 401 00000000 oO E EJ U CI E E O HE oO C U 0 U o 0 U O 0 0 l a 0 Fei L ED ul g B CS oO 4 oO CI q o ar a o a 0 0 O O E 22 o go Ou E l 7 a Oo Ou o D Z OR o E Oo CH B A zt EB DA El o U Oo o D H 77 9 St DO go o o Ou i oo 2 uq p Oo D Oo O 9 jii Go ge ST olg a oo se gE ou Doo 0 be Ba Be E tee SaS aa Are ooo Ooo tar Glen JE KE TD noo 2 ooo OF O MEE ae St Sa ooo Sa o a Of o iif DO mt 5 H o D De E EE BE GE ooo O o 213 2g E Pa ti U Ss 250 noo 0 3 4 EJ e EE Oo OOS C o Ha H ix Sal Sig idi 000202 eos ooo 1 al H tor AI o 2 Op ii i4 aaj 0 a ooo 0 o D Of po Er Doe Foo ooo O 65 oO i EE Ti d 4 gon LI De Ges ei TS A GER a a jm TES Ons ono eal ere H dqiq EA Pe EES Seas 6 Pose CDe y i 50050 Doo Doy ooo o oF Of NE te Et HEEE q AR AT ooog oy Ha D riit Booooo o pop Goto 2o00 0 CIM Ore sO es e Mes Hee c moda Coo Ooo eS too Oboouooo c Oooo Ooo Oooo oo a BS u 080000 o0o000 G ODO Moon oo o OF Ei SS a ogaoga o angoa 2p CC 0 EI See 0 0 0 0 E El ELEF _ 09 000006 SE REE El SE E BH 7 oo 0 E 0 0 E 0 0
6. je 0 OOOO Goor Sooo 0 0 ll 0 p2000 DD 00 Dot 00 0 8800 g2000 le 00 5 Gonzo 00 0 0 28000 Dot 0 2200004 Beene 9 00 0000 000 0 jan 0 0 100 COD COD 0 000 0 0 0 1 p000 8000 00 0 00042 COD 0 00 Doc ei 8000 Gopoppop opop 200042 OOO 70 0 00 8000 CDI 0 0 0 0600 0 0 0000 6050 0 3 0 0 0 moog COD le lo e e ala DR DD a CH ono a oo D O ad D 9 i A OH OA ed ei ei OR E 20140401 PSE RE 405 For Manufacturers outside Japan Conditions for Application for Conformitv Assessment JAPAN ELECTRICAL SAFETY amp ENVIRONMENT TECHNOLOGY LABORATORIES The following conditions shall be accepted for Application for Conformity Assessment TT Matters related to Application J 1 All arrangements necessary for Conformity Assessment shall be made by Applicant including the following All information necessary for evaluation of the Specified Electrical Appliance or Material of which Conformity Assessment is to be carried out shall be provided to JET JET shall be upon request allowed to enter the manufacturing factory and o
7. 0 0 0 0 0 0 0 0 ES 0 000 1 000000000 UU OOO 0000000000 U U U 0000 70 7360 00 20140401 PSE RE 401 Project No ANNEX to APPLICATION FORM Form 4 for CONFORMITY ASSESSMENT 1 Is this your first application Please tick the appropriate box O Yes O No Please fill in the number of the latest Statement of Conformity Assessment below JET S O Renewal Please attach a copy of the valid Statement of Conformity Assessment 2 Please specify the name and post of the representative of the applicant foreign manufacturer ex president amp CEO Mr James Wagner Managerial post Name 3 Agent if applicable Entrusted Person Name 4 The applicant shall submit the following documents to JET for each application O Type Classification Guideline of Type Classification on each product is available on your request O Documents describing the structure materials and performance of the product concerned PSE RE 701 O List of factory s PSE RE 402 O List of Inspection Facilities required for each factory O Technical information photograph drawing list of components and parts circuit diagram an instruction manual and other data necessary for testing O Information for interaction PSE RE 403 5 The applicant shall submit the following documents to JET when necessary O Power of Attorney PSE RE 404 if the application is made by an agent O Application form for
8. of attorney l O Until further notice e g on the change of the agents O From month day year tolmonth day year Please submit a copy of this power of attorney for each relevant application during its validity I Applicant l Signature or seal Applicant Name the applicant manufacturer outside Japan for conformity assessment Division name Managerial post Name of Company Address Tel Fax 20140401 0 0 PSE RE 405 000000 0000000050 DAd ag 0000000000000 1 0000000000 00000000000 1 60 1 00 0 00000000000000000000000000000000000000000000 110 00 0 0100100101000001
9. testing at manufacturer s premises if the testing is to be carried out by JET at the manufacturer s premises O CB test certificate and test report if the data are utilized based on CB scheme 6 Is Test Report to be issued Please tick the appropriate box O Yes Japanese English version for a fee Mention of the model name CINecessarv Model name ONot necessary O No 7 Information on the products for testing Delivery schedule the number of packages and other necessary information O Merely the products for testing are to be dispatched to JET on around Month Day Year The number of packages O The products for testing are to be carried directly to JET on around Month Day Year O The products for testing and the application documents are to be packed together and dispatched to JET on around Month Day Year 8 Action to be taken if nonconformity on EMI is identified If the product is found to fail in EMI test the Conformity Assessment with it shall be stopped totally regardless of the other steps of testing so that the Assessment is to be carried out anew after the product is improved considering the result of the EMI test O Yes O No The result of the Conformity Assessment is to be reported after it is completed 9 Request or information if any 20140401 PSE RE 402 UULUL 00000000 0 U 10 gt 1 0 1 70
10. at the Statement of Conformity Assessment 1s issued shall be stopped when the government gives instructions to prohibit the marking etc 9 The Statement of Conformity Assessment shall be used only to show the fact that the product concerned was assessed and passed 10 When Applicant provides Notifying Supplier in Japan who imports the products concerned with a copy of the Statement of Conformity Assessment application shall be made to JET for issue of an official duplicate of the Statement of Conformity Assessment If a copy of the Statement is provided to other people as a sample the Statement shall be copied entirely 11 Request by JET if any shall be satisfied when the issued Statement of Conformity Assessment is referred in information media such as documents pamphlets and advertisements 12 The records on complaints about Specified Electrical Appliances and Materials covered by the Statement of Conformity Assessment shall be maintained and made available to JET upon request Besides the following steps shall be taken Appropriate measures shall be taken on the above complaints and the products whose conformity to the Technical Requirements of the Electrical Appliances and Materials Safety Law has turned out to be questionable The taken measures shall be set down in writing 13 After Statement of Conformity Assessment is issued JET shall be allowed to make public the registered information Applicant s name the name of Spe
11. cified Electrical appliances and Materials and the Statement Number 14 If JET is requested by law to disclose classified information JET shall be allowed to disclose it after notifying Applicant of the matters about which disclosure is requested 20140401 O Matters related to any nonconformity identified during the Conformity Assessment 15 If a lack of conformity is identified during the product test or the inspection of testing facilities JET gives notice on nonconformity the fact that conformity cannot be achieved without appropriate improvement as a result of the Conformity Assessment Any continuation of the Conformity Assessment with a proposal for the improvement shall be applied within 40 days after the above notice Such an application with a proposal for the improvement cannot be made more than twice O Matters related to products for testing 16 Products for testing shall be delivered to Tokyo Yokohama or Kansai Laboratory as designated by JET Applicant shall be responsible for the transportation 17 If the products for testing are with damage or a defect when delivered and JET informs Applicant about it Applicant shall take measures to meet the situation immediately 18 After the testing JET does not restore the tested products to their original condition and shall not be responsible at all for the disassembly and damage caused by the test 19 Applicant shall collect the tested products within 50 days of the com
12. pletion of the test and have no objection to JETIS disposal of them if they are not collected within the above period The expenses for the return or disposal of the tested products shall be borne by Applicant O Matters related to payment policy for Conformity Assessment feel 20 Applicants are requested to prepay an assessment fee according to JETIS estimate as a general rule If an applicant applies to JET for the first time JET starts testing after JET receives the prepayment If an applicant applies to JET not for the first time an assessment fee may be paid after JET carries out testing but as the case may be JET may request prepayment depending on JET judgment End of document 20140401
13. r contact the manufacturing personnel when JET judges it necessary for Conformity Assessment The person s in charge of the testing facilities etc at the manufacturing factory shall be upon request present in the inspection of the testing facilities 2 The application is incomplete unless JET receives all of the following products for testing and necessary documents 3 If the products for testing and the necessary documents are not delivered to JET within 6 month after the application form is submitted the Application shall be considered to be withdrawn for Applicantis reasons 4 JET may partially outsource the product test and or the inspection of the testing facilities for Conformity Assessment JET informs Applicant it at the time of the reception if outsourcing is adopted Matters related to Statement of Conformity Assessment 5 Statement of Conformity Assessment is valid only to the extent of the stated Type Classification and the fact that the Statement of Conformity Assessment is issued cannot be made public without the valid Statement of Conformity Assessment 6 The fact that the Statement of Conformity Assessment is issued shall not be announced in such a way that may injure JETS reputation 7 The fact that the Statement of Conformity Assessment is issued shall not be announced in such a way that is not permitted by JET or that may lead to misunderstanding 8 The use of all advertisements referring to the fact th
14. the application CI Agent as specified in Annex to the application O Point of Contact No below CI The applicant collects the tested products O JET is to dispose of the tested products small sized products only The applicant bears the expenses for the disposal Point of Contact No 1 Name of company Address Name of person in charge Division name Managerial post Tel Fax E mail Point of Contact No 2 Name of company Address Name of person in charge Division name Managerial post Tel Fax E mail 20140401 PSE RE 404 U U U 008 000000000 00 UU U U UU 00 U 0 0 0 00000000 ooo OUU OOUUUU 11 0 0 1 0 4 UU U Ul ooo UD OOUUUU 11 0 0 ooo ooo UU U U DO 1 OOO 0 ULULL 000000 ULL U U 0001 078 p00000000000000000000 O U 1 1 098 0 20140401 PSE RE 404 POWER of ATTORNEY month day year To Japan Electrical Safety amp Environment Technology Laboratories I hereby entrust the following person as agent of the applicant with full power for the application for conformity assessment under the Electrical Appliance and Material Safety Law Agent Signature or seal Entrusted Person Name Division name Managerial post Name of Company Address Tel Fax I Validity of this power
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