1.	Reference Number:
	Name of Applicant
	Address
	Address
	Town
	Country
	Post Code
	Telephone
	Fax
	Email
	Contact
	Position
2.	Name of Manufacturer (if different from applicant)
	Address
	Address
	Town
	Country
	Post Code
	Telephone
	Fax
	Email
	Contact
	Position
3	Name of Factory (if different from manufacturer)
	Address
	Address
	Town
	Country
	Post Code
	Telephone
	Fax
	Email
	Contact
	Position
4	Product Name
	Model Number
5	Input Voltage, Current and Frequency
	Power consumption
	Output Current and Voltage
	Highest Frequency generated or used within the product
6	EMC Testing required		2004/108/EC EMC Directive
			1999/5/EC RTTE Directive
			FCC
			IC
			RCM
			E/e-mark
			BSMI
			VCCI
			CCC/CQC
			Other (please specify)
7	Safety Testing		2006/95/EC Low Voltage Directive
			2006/42/EC Machinery Directive
			GS
			CB
			UL + cUL
			CCC
			cTUVus
			ETL + cETL
			SAA
			CSA
			PSE
			NOM
			SPRING
			Other (please specify)
8	Energy Efficiency Testing		LED Integral Lamps
			LED Luminaries
			Compact Flourescent Lamps
			Lighting Facts
			DLC
			874/2012
			ErP EU No 244/2009 EC No 1194/2012
			EELS
			ELI
			Other
9	Information provided with the application		Adapator Safety Certificate
			Block Diagram
			Schematic and Operation Description
			Label and Location on Product
			FCC Grantee Code
			IC Company Code
			PCB Layout
			Bill of Materials
			Exploded Diagram
			FCC ID(14)
			IC UPN (8" - ")
			Critical Component List & Cert.
			Spec of Transformer
			PCB Placement
10	Report Language First Langauge free, £500 for each additional languge		English
			Chinese
11	Report Delivery		Express £15 fee (in advance invoiced with the testing
			Express Address:
			Same as Applicant
			Same as Manufacturer
			Same as Factory
			Collection
			Email
12	Sample handling after testing Valuable or Hazardous samples should be collected Samples will be disposed of three months after testing is complete, if uncollected		Collection
			Shipping
			Disposal by CTI
13	Invoice Delivery		Same as Applicant
			Same as Manufacturer
			Same as Factory
			Other (Please Specify)
	Any other information
	Name of authorised representative
	Position
	Date