APPLICATION FOR TESTING OF ELECTROMAGNETIC COMPATIBILITY (EMC) AND/OR ELECTRICAL SAFETY (LVD) COMPLIANCE WITH ESSENTIAL REQUIREMENTS
specified in the EMC directive No. 2004/108/EC and the LVD Directive No. 2006/95/EC

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:	
Person authorized to negotiation:	

Product:
Product name:
Type/Model and applied voltage:	
Manufacturer’s company name and address (if different from that of the applicant):

Accompanying documentation:
Required language versions of issued test reports:		 Czech	 English	 other (            )	
Required output of the testing:		 test report	 attest	
Testing shall be aimed to (check off one or both boxes):		 electrical safety	 EMC 	
Instructions for use, eventually assembly instruction:		
Technical conditions (figures and drawings, circuit schemes, characteristics of the product, warnings, labelling etc.):		
Test reports of other accredited laboratories:		
Harmonized standards and other specifications for which compliance testing is ordered:		
Other documents and information:		

Applicant’s declaration: 
1.	We agree that our product samples will not be returned back after testing if not otherwise specified.
2.	We agree with the “Obligatory Business Conditions” of ITC and we will abide by them.

    Date of Application	Stamp and signature of applicant’s representative