application for Product CERTIFICATE ISSUe

No.:										
	ITC’s Registry Number (do not fill in)

APPLICANT:
Company name:	VAT No.:											
	Registration No.:									
	Registered at:		
Address:	Phone: 		
	Fax:		
Zip Code:			-							e-mail:	@	
Banking with:		Account No.:		
IBAN:		SWIFT Code:		
Represented by:	
Contact person authorized to conduct negotiations:	

Product:
Name:

Type:	
Company name and manufacturer’s address (if different from that of the applicant):

Accompanying documentation:
Certification will be performed by (do not fill in – to be determined by an ITC's certification worker)	 Product Certification Body No. 3020
 ITC Product Certification Body	
Required foreign language versions of the documents issued:	 Czech	 English	 other (               )	
Technical specification (standard, legislative document, other regulation) laying down requirements for the certified product:		
Technical standards and other technical specifications used in designing the product:		
Technical conditions (manufacture technology, drawings and schemes, catalogue sheet, user’s manual, associated legislation etc.):		
Certificates of management system (if any), audit reports:		
Reports issued by foreign accredited testing laboratories:		
Other documents and information:		

Applicant’s declaration: 
1.	We agree that product samples will not be returned after assessment.
2.	We agree with a quality surveillance of the products for which the product certificate has been issued.
3.	We agree with the “Obligatory Business Conditions” of ITC and we will abide by them.

    Date of Application	Stamp and signature of applicant’s authorized representative