Type Approval Application Checklist
Document checklist

Details:(to be completed and documents submitted
by the Manufacturer/ Applicant)

1. Applicant: (Company Name and Address of each location, Phone Number, Email address, Contact
Person. Please provide information relating to your human and technical resources (including laboratories
and/or inspection facilities), and its functions and relationship in a larger corporation/group, if any)☐

Existing ISO 9001 certificate☐

Existing ISO 9001 certificate☐

Written mandate☐

Existing ISO 9001 certificate

申込者の住所、電話番号、E-mail、担当者様のお名前を入力下さい。

2. Manufacturer: (if different from 1: Company Name (in full) and Address (Street name and number,City, State (if applicable), Postal Code, Country), Phone Number, Email address, Contact Person. Please
explain your relationship with the Applicant, any relevant legal obligations)
Please note:
A. This Company name and address will be listed on the certificate

製造者が 1．と異なる場合、住所、電話番号、E-mail、担当者様を入力下さい。

3. Authorized Representative: (Name (in full) and Address (Street name and number, City, State (ifapplicable), Postal Code, Country), Phone Number, Email address, Contact Person).
Please note:
A. This is required for the Manufacturers not located in the territory of at least one European Union
member State applying for the MED Certification but not for countries covered under below footnote 1).
B. Details of Authorised Representative will not be listed on the certificate

MED で認定代理人がいる場合、会社名と住所を入力下さい。

4. Place(s) of Production: (if different from 1 or 2: Company Name (in full) and Address (Street nameand number, City, State (if applicable), Postal Code, Country), Phone Number, Email address, ContactPerson.).
Please note:
A. Details of places of productions to be provided

製造場所が 1．又は 2．と異なる場合、住所、電話番号、E-mail、担当者様を入力下さい。

5. For application for Module D or E only (MED and UKCA): Please provide
information required in 5A – to 5D for each Place of production:
MED 又は UKCA の Module D 又は E の場合、各々入力下さい。

MED – Module D or E
5A. Total number employees at the site:
5A1: No of shifts:
5B Total number of employees involved in the MED production (effective staff):
5C: No of Module B’s applicable for the company/location
5D: No of MED categories
UKCA – Module D or E
5AA. Total number employees at the site:5AA1: No of shifts:
5BB Total number of employees involved in the UKCA production (effective staff):
5CC: No of Module B’s applicable for the company/location
5DD: No of UKCA categories
For Man Day calculation (for MED and UKCA) refer to section 11
6. Product:
申込み頂く製品の情報を各々入力下さい。

Name (to be provided):
Description (to be provided):2

Item number (for MED certification) - refer to below footnote ): MED/

Please note that below
documentation is required to beprovided by the
Manufacturer/Applicant with eachapplication:☐ General/functional description ofthe product

Lloyd’s Register Group Limited, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clauseas ‘Lloyd’s Register’. Lloyd’s Register assumes no responsibility and shall not be liable to any person for any loss, damage or expense caused by reliance on theinformation or advice in this document or howsoever provided, unless that person has signed a contract with the relevant Lloyd’s Register entity for the provision ofthis information or advice and in that case any responsibility or liability is exclusively on the terms and conditions set out in that contract.

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Type Approval Application Checklist
Document checklist

Details:(to be completed and documents submitted
by the Manufacturer/ Applicant)☐ Technical documentation
including test report(s)☐ Copies of accreditation
certificates and schedules (forthe test house(s))☐ Analysis and assessment of risk(s)☐ Product Specification/Literature/
data sheets☐ Design Drawings, sufficient tofully define the product☐ Software Quality Plan3

Item number (for UKCA) - refer to below footnote ): UK/
Type (to be provided):
Application:

Marine/Offshore/Industrial (delete as appropriate)

Ratings (to be provided):Standards and other normative documents for which certification is sought:
Other conditions (to be provided):4

7. Type Approval Certificate: (Must be marked; Multiple options may be applicable) )該当する項目にチェックして下さい。（複数選択可）☐☐

LR Type Approval
New☐

☐
☐

MED LRMD
NewRenew☐ AmendRenew☐ Amend☐

Copies of existing Module B
EC and /or UK Type
Examination Certificates☐Copies of EC and/or UKDeclarations of Conformity☐

Copies of any other Relevant
Existing Certificates

6☐☐Module B ☐Module D ☐Module E ☐Module F ☐Module G ☐US CoastGuard
6☐ UKCA LRM Ltd☒ New☐

Renew

☐ Amend☐Module B ☐Module D ☐Module E ☐Module F ☐Module G ☐US Coast5Guard☐☐

EU Mutual RecognitionNew☐
Renew

☐

Amend

☐
☐

MCANew

☐

Renew

☐

Amend

☐
☐

Transport CanadaNew
☐

Renew

☐

Amend

☐ Draft LR Type Approval Certificate required (will be issued prior to issue of final
Certificate in order to allow a review)
8. For Renewal or Amendments to an existing Certificate please provide current/
previous Certificate Number(s):In addition, if you have a Module D/E Certificate(s) (MED or UKCA) to be amended
please list the Certificate number:
更新又は変更の場合、既存証書番号を入力下さい。

9.Have any changes/amendments been made to the following since previous
7Certificate(s) was/were issued?
変更又は更新の場合、前回からの変更の有無をチェックして下さい。

Product☐Yes ☐No

Documentation ☐Yes ☐No
Technical files previously submitted to LR

If yes, to any changes pleaseprovide:☐ Detailed description of changes☐ Relevant documentation☐Yes ☐No

Lloyd’s Register Group Limited, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred caused byreliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the relevant Lloyd’s Register entity for theprovision of this information or advice and in that case any responsibility or liability is exclusively on the terms and conditions set out in that contract.to in this clauseas ‘Lloyd’s Register’. Lloyd’s Register assumes no responsibility and shall not be liable to any person for any loss, damage or expense

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Type Approval Application ChecklistDocument checklist

Details:(to be completed and documents submitted
by the Manufacturer/ Applicant)

10. Do you outsource any processes, production, or activities relating to yourMED/UKCA activities? Please note that for Module D/E an audit at suppliers can benecessary and additional audit days required.

☐If yes, please provide details,
including information concerning
all outsourced processes usedthat will/may affect conformity
to requirements; if another legal
entity is used for producing thecertified product(s) that isdifferent from your entity, thenappropriate contractualarrangements shall beestablished with that entity.

外部委託の有無をチェックして下さい。
有の場合には詳細を入力下さい。

☐ Yes☐No11. Testing:☐

電気機器の場合、該当する使用環境にチェックして下さい。

Specified standards: (Including (Inter)National standards, InternationalConventions, Rules)☐

Proposed Test Programme,
Test Report/Drawings
Existing Test Reports

Environmental Testing in accordance with LR Test Specification No. 1:☐ ENV1 – controlled environments only, to producer´s specification☐ ENV2 – enclosed spaces subject to temperature, humidity and vibration: 5°C
to 55°C☐ ENV3 – enclosed spaces subject to generated heat from other equipment:
5°C to 70°C
☐ ENV4 – mounted on reciprocating machinery: 5°C to 55°C
☐ ENV5 – open decks: -25°C to +70°C☐ Additional tests e.g. IP65: please state
12. Man Day Calculation (To be completed by LR):
LR 利用欄につき入力不要です。
SiteStandard / CodeType of Visit

Approx. Man Days
WorkTravel

Man Days of follow up visits
WorkTravel

13. Please provide all other information such as information for initial evaluation and surveillance activities, e.g., the locations
where the certified product(s) are produced and provide contact details for personnel at these locations.
初回検査を行う際に必要な情報（認定品を製作している場所、担当者様など）があれば入力下さい。

14. Comments:
その他に何かあれば、又はどこに書いていいか分からない事項があればここに入力下さい。

Lloyd’s Register Group Limited, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred caused byreliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the relevant Lloyd’s Register entity for theprovision of this information or advice and in that case any responsibility or liability is exclusively on the terms and conditions set out in that contract.to in this clauseas ‘Lloyd’s Register’. Lloyd’s Register assumes no responsibility and shall not be liable to any person for any loss, damage or expense

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Type Approval Application Checklist
Document checklist

Details:
15. Declaration:(to be completed and documents submitted
by the Manufacturer/ Applicant)

16. Client ‘s Name (block capitals please):

15.1 I declare that information provided is true and
代表者様の氏名、署名、日付を入力下さい。
complete and that the same application has not been
lodged with any other notified body
Signature:
15.2 I declare that information provided is true andcomplete and that the same application has not been
lodged with any other UK approved body
15.3 Applicable only to UKCA certification, to be issued
based on the valid MED certificates issued by one of theLR entity (LRV Ltd., LRV BV, LRD and LRMD) - delete if
not applicable:

Date:

I am confirming that my company is giving LRM Ltd.
permission to obtain technical documentation from oneof LR entity (LRV Ltd., LRV BV, LRD and LRMD), whichhave been submitted during the certification process ofmy equipment under the Marine Equipment Directive(2014/90/EU)
17. Application review conducted by (Name, date andsignature):(LR use only) LR 利用欄につき入力不要です。
Footnotes:1)The Agreement on the European Economic Area, in force since 1 January 1994, covers all Union harmonisation legislation thus, Union harmonisation legislation
also applies to the so-called EEA EFTA States: Iceland, Liechtenstein and Norway. The requirement for the appointment of an Authorised Representative is notapplicable for those countries.
Since from the end of 2020, the Protocol on Ireland/Northern Ireland (‘IE/NI Protocol’) applies for a period of 4 years. The IE/NI Protocol is subject to periodic
consent of the Northern Ireland Legislative Assembly. According IE/NI Protocol EU rules apply, and Northern Ireland is assimilated to a Member State. The
requirement for the appointment of an Authorised Representative is not applicable for Northern Ireland for the time of the validity period.
2) Please ensure that the MED item number of the Implementing Regulation of the product is provided. (e.g., MED/3.16 etc.). when applying for MED
Certification. If the manufacturer does not know the correct MED item number, the manufacturer must seek advice by LR CFO or a local contact for MED.

3) Please ensure that the UKCA item number is provided. (e.g., UK/3.16 etc.). when applying for UKCA Certification .For the correct item number refer to Annex
1 of the up-to-date version of MSN1874 - Marine Equipment - United Kingdom conformity assessment procedures for marine equipment, Other Approval andStandards Merchant shipping notices (MSNs) - GOV.UK (www.gov.uk)
4) Please ensure that the New OR Renew OR Renew and Amend OR Amend box is selected, as appropriate when applying for any Certification. Please also
ensure that current certificate(s) number is provided in Section 75) This is approval for the equipment within the scope of the Agreement between the United Kingdom of Great Britain and Northern Ireland and the UnitedStates of America on the Mutual Recognition of Certificates of Conformity for Marine Equipment dated 14 February 2019 (UK-USCG MRA)

6) For more information about the MED and UKCA refer to the document The Marine Equipment Directive, the EC-US Mutual Recognition Agreement on marineequipment, the UK Conformity Assessment (UK Regulations) and the UK-US Mutual Recognition Agreement on marine equipment - Guidance for manufacturers
available from the LR website Marine Equipment Directive from Lloyd's Register (lr.org)
7) If you are applying for more than one certificate, to avoid any confusion and delay the process, please provide this information for each certificate separately

Lloyd’s Register Group Limited, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred caused byreliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the relevant Lloyd’s Register entity for theprovision of this information or advice and in that case any responsibility or liability is exclusively on the terms and conditions set out in that contract.to in this clauseas ‘Lloyd’s Register’. Lloyd’s Register assumes no responsibility and shall not be liable to any person for any loss, damage or expense

Version 1. May 2022