application for concession to use certification mark 
„ITC-Certified quality“

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 of product or product type:

The type series includes specific elements as follows:	
Company name and manufacturer’s address (if different from that of the applicant):

enclosed documents and details:
We are enclosing valid ITC type or product certificate:	 yes (Doc.No.:                             )	 no 	
We are enclosing valid ITC test reports:	 yes (Doc.No.:                             )	 no 	
Expected initial date of the marking use:		
Requirements for language versions of issued documents:	 Czech       English    other (               )	
Instruction for use, maintenance, information for users:		
Technical conditions (product characteristics, manufacturing method, risk analysis, drawing documentation, harmonized and other standards used, marking, illustrations, etc.):		
		
Methods and criteria of conformity assurance of all products with the type, certificates of quality control system, audit reports:		
Reports by foreign accredited testing laboratories:		
A list of the countries where the given products are sold:		
Additional documents and information:		

Applicant’s statement: 
1.	We have acquainted ourselves with the Rules for use and maintenance of the “ITC Certified Quality” mark and agree to their requirements.
2.	We agree to a random sampling of products provided with this mark in the market or distribution warehouses.

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