TÜV Rheinland Japan Ltd.
TelCustomer Service / East japan: 045-470-1850
Customer Service / West Japan: 06-6355-5400

National Certification Body (NCB) in the CB scheme
TelFaxGTAC / Yokohama: 045-914-3888 045-914-3377
KTAC / Osaka:
06-7656-6888 06-7668-5777

Please markas applicable. Submit with page 2 by e-mail to a contact staff ( or FAX (kindly avoid duplicate sending)).
All the information in this application form must be treated as confidential !

Page 1/2

This Ref. No. will be shown on TÜV documents such as an invoice

APPLICATION1. APPLICANT

Customer Reference No

Coordinator in this project / Fill in Bilingual(or attach the bilingual name card)

Same as Estimation

Estimation No:

Company Name:
Address,Post Code:Department:
Section:Contact Person, Title:
Tel:

Same as Estimation (leave blank 2A-2H if same as estimation)

2. SERVICE TYPE
2AFax:

e-mail:Test Mark License(Note) Annual fee will be charged separately from this project fee.

GS

TÜV
GM
EMC
Telecom
TÜV-S (Japan)
S-TÜV (Japan)
Ergonomics
DIN CERTCO
Other:SEMI S2CTUVUS (C/US)S-Mark (Argentina)

Test report
2B

CB Certificate (Certificate & Report)

National Deviations: e.g. Korea (60Hz)

2C

DENAN / CoC (Certificate of Conformity)

Number of Certification Copy

Worldwide Market Access(Note) Please note that respective Certification Body/Authorityof the country may require Annual Fee and Factory Inspection
Fee, whereas such conditions will be clarified individually.

2D

CCC
EAC
RCM

SRRC
INMETRO
Energy Star

NAL
BSMI
ANATELNOM
Specific Research

NCC
IFETEL

KCApproval other than above (ex. India Product Safety, Thailand Wireless Approval, etc.)
Please specify country and approval type below or in separate attachment:

Reference (same model)
License/Certificate No.:
Additional Application for existing License / Certificate(Note) Please attach the detailed description

2E

CE marking/CoC (Certificate of Conformity)

2F

Report/Certificate No.:
LVE

Machinery

EMC

RED

S2

S8

Others:Others:Test report
2G

SEMI Report

2H

Test Report

2I

Other service (e.g. evaluation, pre-test, consulting, etc.):

Decision rule of Statement of Conformity to ISO/IEC 17025
2J

TUV Rheiland Japan : Zero Guard Band rule( refer to https://www.tuv.com/japan/en/lp/lp-decision-rule/ )3. PRODUCTFill in English(Bilingual for TÜV-S, S-TÜV orDENAN/COC)

If other specific rule should be applied by customer requirement,
please check below box (need detail requirements before quotation)
Customer requirements

Target Deliverly Date(yyyy/mm/dd)

Product:
Model:

4. PROJECT FEE Receiver

Fill in Bilingual(or attach the bilingual namecard)

Same as 1.APPLICANT (leave blank)

Company name:
Address, Post CodeDepartment:
Section:Contact Person, Title:Tel:e-mail:Fax:

The General Terms and Conditions of Business of TUV Rheinland Japan Ltd. https://www.tuv.com/jp-gtc-en
and the relavant Testing and Certification Regulation apply. https://www.tuv.com/japan/en/about-us/download-document/

DateSignature or Stamp＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
Printed Name
Version: 2022-08-01

TÜV Rheinland Japan Ltd.
Shin Yokohama:
GTAC Yokohama:
Osaka:KTAC Osaka:
Kyushu (Fukuoka):<for the TEL/FAX, please refer to page 1>

Daini Center Bldg., 3-19-5, Shin Yokohama, Kohoku-ku, Yokohama 222-0033
Global Technology Assessment Center, 4-25-2 Kita-Yamata, Tsuzuki-ku, Yokohama 224-0021
Wakasugi Center Bldg., Honkan 16F, 2-9-1 Higashi-Tenma, Kita-ku, Osaka 530-0044
Kansai Technology Assessment Center, 1-3-14 Fukae Minami, Higashinari-ku, Osaka 537-0002
NMF Hakataekimae Bldg. 2F, 1-15-20 Hakataekimae, Hakata-ku, Fukuoka 812-0011

Please markas applicable and submit together with page 1.
All the information in this application form must be treated as confidential !

APPLICATION

Page 2/2

Fill in same Ref. No. as in page 1

Customer
Reference No
Fill In English (Bilingual for TÜV-S, S-TÜV orDENAN/COC)

5. LICENSE HOLDER

Same as 1. APPLICANT (leave blank) / This Company Name andAddress will be shown in License holder on the License and in holder on theCertificate of Conformity

Company Name:Address, Post Code:Fill in English(For CB Certificate Only)

6. CB APPLICANT & MANUFACTURER
Same as 1. APPLICANT

Whenis ticked, leave blankSame as 5. LICENSE HOLDER

CB Certificate APPLICANT:
Company Name & Address:
Same as 1. APPLICANT

Same as 5. LICENSE HOLDER

CB Certificate MANUFACTURER:
Company Name & Address:

7. FACTORY / Manufact. Plant(CB Cert.)/(License)

Fill in English (Bilingual for TÜV-S,S-TÜV or DENAN/COC)

Factory List is attached (for 3rd factory)

Fill in Bilingual(or attach the bilingual name card)

Same as 4.PROJECT FEE (leave blank)(1)Factory Name & Address:
Never Inspected by TUV Rheinland(2)Factory Name & Address:
Never Inspected by TUV Rheinland

8. ANNUAL FEE Bill ReceiverCompany Name:
Address, Post Code:Department:
Contact Person, Title:

Section:Tel:e-mail:Fax:

9. REMARKS

Use for additional information(desired payment schedule, Test schedule, Sample information, etc.)

Rating:Protection class:Standard or Directive:
Other:

10. MAILING Receiver(Other than invoice. Documents issued by TUV Rheinland after a project is closed)

Same as 1. APPLICANT
Same as 4. PROJECT FEE ReceiverSame as 8. ANNUAL FEE Bill Receiver

11. Test Report ・ Photo Documentation Form
Test Report

PDF via Email (standard)

PDF via CD-ROM (Chargeable)

Hard Copy (Chargeable)

Photo Documentation

PDF via Email (standard)

PDF via CD-ROM (Chargeable)

Hard Copy (Chargeable)

12. Sample Return or Disposal after Test
Treatment:

If not otherwise agreed, TUV Rheinland Japan will keep sample(s) for up to 6 months
after testing. After that, sample(s) may be processed as selected below. In case notreatment is selected, samples may get disposed.

Return (Chargeable)

Pickup (Free of charge)

Disposal by TUV (Chargeable)

Same as 1. APPLICANT

Same as 4. PROJECT FEESame as 8. ANNUAL FEE

In case of return:
Others:13. Publication on Online Certificate Datases
Such as Certipedia / IECEE (Public area)(If no tick box is selected, certificate data will automatically be published online,
shortly after the certificate has been issued)

Certipedia
No online publication
month(s) after certification (maximum 6 months)
immediate after certification

IECEE (Public area) - CB certificate only

About Certipedia service
About IECEE (Public area)

No online publication
month(s) after certification (maximum 6 months)
immediate after certification

Caution: the German GS Mark license and the North American cTUVus (C/US)
license are mandatory for publication in Certipedia in accordance with local laws
and regulations.

No online publication of above services

Version: 2022-08-01