Application Form for New IECExCoC, ExTR and QAR Under the Equipment Certification Scheme of the IECEx System of applicant 申請者名Name of applicant 申請者住所Address of manufacturer 製造者名Name 製造者住所 Address of manufacturer name 品名Product reference 型式Model/Type of protection 防爆構造Types IEC 60079- 0 : (ed. ) standards IEC 60079- : (ed. ) 適用規格Applicable IEC 60079- : (ed. ) Code/EPL Ex II T G 防爆記号/EPL 定格Rating 依頼認証書 IECExCoC ExTR QAR □ □ □ Request for issuing of Off-Site Testing Witness Testing site □ □ 出張試験・立会試験Testing 201*/**/** 日付Date of applicant company 申請者名Name representative person 代表者Authorized 役職／職位Title/Position 氏名Name サインSignature
Application Form for New IECExCoC, ExTR and QAR Under the Equipment Certification Scheme of the IECEx System 申請者名Name of applicant 申請者住所Address of applicant 製造者名Name of manufacturer 製造者住所 Address of manufacturer 品名Product name 型式Model/Type reference 防爆構造Types of protection 適用規格Applicable standards IEC 60079- 0 : (ed. ) IEC 60079- : (ed. ) IEC 60079- : (ed. ) 防爆記号/EPL Code/EPL Ex II T G 定格Rating 依頼認証書 Request for issuing of □ IECExCoC □ ExTR □ QAR 出張試験・立会試験Testing site □ Off-Site Testing □ Witness Testing 日付Date 201*/**/** 申請者名Name of applicant company 代表者Authorized representative person 役職／職位Title/Position 氏名Name サインSignature