PCM-78-YL-Ed.4.5
Application Form for Entrusted Test
JET project no.
Date:
To: the President of Japan Electrical Safety & Environment Technology Laboratories
The Person Responsible for Application
Company Name :Company address：
Working Division:
Person in charge :＿＿＿(signature/seal)

Applicant agree with all Stipulations for Entrusted Test and all statements in the attached
Agreement and hereby apply for Entrusted test for the following product.
（it is acceptable to use a separate sheet for items 1 to 4 and 13 listed below. ）１．Electrical Product Name:
２．Model of electrical product to be tested (Catalog number, etc.)
３．Product Ratings (rated voltage, rated frequency, rated current, wattage, etc.)
４．Test standard & test items:
５．Test Report (Report in simple version only with test result, report in detail version also withtest data, etc. For request of English test report, please provide applicant Company name, address,
product name in English.)☐ Detail version (in Japanese: with fee charged)☐ Detail version (in English: with fee charged)☐ Simple version (in Japanese: free charge)☐ Simple version (in English: with fee charged)☐ Not necessary※Either for detail version or simple version test report, only 1 copy of original can be issued.
☐＿＿＿copies (with fee charged)☐ Duplicate of test report

６．Stating of PSE mark in Test Report: (For products subject to Japan Electrical Appliances andMaterials Safety Law only)
☐ Yes

☐ No

７. Certificate of Test Report(with fee charged):(issuance subject to the test report in detail version)
☐ Yes

☐ No

８．Revised Test: (For no request of revised test, the project will be closed in failed test result)
☐ Yes

☐ No

９．Urgent Service Request: (For urgent request, test expense in double or more will be charged)
☐ Yes

☐ No

10．EMC Test: (For application only for EMC Test)☐ 50Hz☐ 60Hz☐ 50-60Hz☐ either 50Hz or 60Hz which has higher noise level

11．Confirmation on disassembly of test samples: Depending on Test items, test samples may bedisassembled and damage may be occurred because of the sample disassembling☐

Applicant agree to disassemble the test samples (test may not be proceeded without Applicantagreement)

12．Contacting

person for the application (for contacting about the application, receiver of theinvoice, test report, etc.)
Company Name:
Company Address:
Working Division:
Contacting person’s name:
TEL:

FAX:

e-mail:13. others (other request about the application)

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PCM-78-YL-Ed.4.5
ＡＧＲＥＥＭＥＮＴ
Applicant agree with the following statements and apply for Entrusted test to JET.
１．The Person Responsible for Application shall take full responsibilities for the entrusted test.
It should inform JET immediately if The Person Responsible for Application changes during test.
２. JET shall use any and all information obtained from the applicant regarding the product and its
manufacture only for this entrusted test, and shall not use it for any other purpose or leak it
to any third party without the permission of the applicant or any justifiable reason, such as
pursuant to the laws and regulations. However, this excludes information that was publicly knownat the time of application, information that became publicly known after acceptance without intent
or negligence on the part of the Institute, and information that the Institute has legally obtained
from a third party.
３．The applicant shall deliver test samples, revised samples to one of the following Labs. Theapplicant shall take full responsibilities for sample delivery.
Japan Electrical Safety & Environment Technology Laboratories☐

Tokyo Lab/5-14-12 Yoyogi, Shibuya-ku, Tokyo, 151-8545, Japan☐

Yokohama Lab/1-12-30 Motomiya, Tsurumi-ku, Yokohama, Kanagawa, 230-0004, Japan☐

Kansai Lab/4-1 Koyo-cho Nishi, Higashinada-ku, Kobe, Hyogo, 658-0033, Japan☐

Power Technology Testing Lab/1-12-28 Motomiya, Tsurumi-ku, Yokohama, Kanagawa, 230-0004, Japan☐Fukushima PCS Testing Lab/2-5-1 Machiikedai, Koriyama, Fukushima, 963-0215, Japan

４．Generally the applicant shall pay test expense in advance.
Applicant, who apply for PSE test at JET for the first time, shall pay the test expense before JET
start the test(except for those applicant’s special request admitted by JET).
However, applicant who already have done PSE projects at JET may pay the test expense after test,
but JET still reserve the right for prepaid request.
５．The applicant shall take action immediately after JET inform test samples have damage .
６．When determining the test results, unless we receive a specific request from the applicant,our organization's decision rules will be applied.
７．JET will send Revising Notice to applicant when the test samples fall in test. The applicant should
arrange payment immediately in case there is any short payment to the pre-paid test expense.
８．In case JET find major defects on the samples during test and judge that the samples with such
defect won’t comply with Technical Requirements, JET will treat the application as follows:
1) sending revising notice to applicantor2) recommending withdrawal of application while sending Revising Notice to applicant
９． Tested samples will be returned to the applicant with the condition being disassembled or damaged
after test. JET take no responsibility for damage or disassembly of the samples due to test.
Additionally, the number of packages may unavoidably increase or decrease when returning.
10．The applicant shall decide how to handle the tested samples.
☐ The tested products are to be sent to (with payment to be made by the addressee):☐ Responsible person for the application☐ Agent as specified in Annex to the application☐ The applicant takes away the samples.
☐ Discard tested samples at JET. (small-sized products only) The applicant bears the expenses forthe disposal.
11． In case this application of entrusted test is to be used for certification (including CBCertification), it shall obey the certification rules and submit all of the necessary productinformation for certification.

Applicant: ___________________(signature)
Signed person’s nameDate:

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