^WEEE^T^esting^R^equisition^F^orm^大连三洋家用电器有限公司专用测试申请表^Form No.:1000085

Applicant Name (单位英文名称)

________________________________________________________

^Official Use Only

申请单位名称 :

________________________________________________________________________

^Rpt. No.:^STH0

Address (单位英文地址):

_______________________________________________________________

申请单位地址:

______________________________________________________________________

^Deposit :

^Contact Person 联系人:

^Telephone 电话:

^Fax 传真:

邮编:

Payer Name (付款单位): o Same as Applicant (同申请公司) o 不同, 请注明_______________________________________________

Address (地址): ______________________________________________________________________

Department 部门: __________

^Contact Person:

^Telephone 电话:

^Fax 传真:

邮编:

^Report Delivered To:o Applicant o Payer Invoice Delivered To: o Applicant o Payer 报告原件寄至 上述申请公司 上述付款公司 发票寄至 上述申请公司 上述付款公司

Company Name & Address shown on Test Report (if different from the Applicant Name Above): 测试报告上所注明的单位名称及地址 (如果与以上申请单位不符): ___________________________________________________________

Sample Description样品描述 c Item / c Article / c Model / c Style No.式样编号 No. of Sample Submitted样品数量 Buyer’s Name买家名称:_________________________ P.O. No.:_________________________ c Supplier / c Vendor / c Manufacturer 供应商/贸易商/生产商:________________________________________________________ Goods Exported to产品运往: Country of Origin原产地:

^Test(s) Required (Please tick appropriate boxes) : 测试要求

o Cadmium (Cd)/ Cadmium Compounds 镉和镉化合物

o Mirex 灭蚁灵

o Lead (Pb)/ Lead Compounds 铅和铅化合物

o Formaldehyde 甲醛

o Mercury ( Hg ) / Mercury Compounds 汞和汞化合物

o Tributyltin Compound & Triphenyltin Compound) 有机锡化合物

o Hexavalent-Chromium (Cr VI ) Compounds 六价格化合物

o Asbestos 石棉

o PBB/PBDE 聚溴联苯/多溴联苯醚

o AZO compounds 偶氮化合物 (22项)

o Polychlorinated biphenyls (PCBs) 多氯联苯

o PVC Identification 聚氯乙烯以及聚氯乙烯混合物定质测试

o Chlorinated paraffins 氯化石蜡 (C10~C13)

o 94/62/EEC Toxic Element Test on Packaging Material 包装材料测试

o Polychlorinated Naphthalene (PCN) 多氯化萘

o TBBP-A-bis 四溴双酚-A-双- (2,3-二溴丙醚)

o Chlorofluorocarbons (CFC) / Hydro chlorofluorocarbons (HCFC) Other 其它：

^Service Required:

o ^Regular 普通件

o ^Express (40% surcharge) 加急件

o ^Shuttle(100% sur charge) 特急件

o Same Day

^Report Service:

o ^Fax 传真

o ^Mail 挂号信

o ^Express Mail 特快专递

o ^Self Pick-Up 自取

Return Sample:

o Yes

o No

o 英文报告—默认的报告格式

o 中文报告

o 中文＋英文报告各一份（加收￥220）

We request for the above tests and agree that all testing will be carried out subject to INTERTEK TESTING SERVICES scale of charges as set forth in their latest price list of which we have seen a copy and upon and subject to the terms and conditions set out hereon and overleaf.

日期

付款公司盖章及代表签名

Date:

Authorised Signature and Company Stamp of the Payer:

(条款祥载背面)(P.T.O.For terms and conditions)

Notes :	1.Applicant should retain the Duplicate for own reference and present the same for collection of test report in our office.
	2.No comment may be given for some of the test items if related standard or specification is not available.