【PSE202401】

様式第四（第2号検査／海外製造事業者用）

Form 4適合性同等検査申込書
Application for Conformity Assessment

受付番号：Project No.

一般財団法人電気安全環境研究所（JET記載欄）(To be filled in by JET)

御中

To Japan Electrical Safety & Environment Technology Laboratories

電気用品安全法第9条第1項に規定する同条第2項の証明書と同等なものの確認を受けたいので、申込書別紙の「適合性同等検査申込みに係る承諾事項（PSE-RE-405）」の内容を承諾の上、次のとおり申し込みます。
We hereby apply for Conformity Assessment on the Specified Electrical Appliances and Materials as stated below, in order toobtain the Statement of Conformity as specified in the Article 9, Paragraph 1 of Electrical Appliances and Materials Safety
Act. We submit this application accepting “Conditions for Application for Conformity Assessment (PSE-RE-405)” on theattachment to the application.

1.

申込者（海外製造事業者） Applicant (manufacturer outside Japan)
会社名Company name

住Address

所

責任者名

The person responsible for the application（署名又は捺印）(Signature or seal)

所属・役職

責任者の住所Division / Managerial position

Address of the responsible person (If different from the above one of the Company)(上記と異なる場合)

TEL：
E-mailFAX：

2. 申込内容の詳細
Details to the application

別紙のとおりAs shown in the attachment3.

適合同等証明書副本交付：
Official duplicate of the Statement of Conformity□ 有（need部）
copy/copies□ 無
Not necessary

【PSE202401】
ANNEX to APPLICATION FORM (Form 4)

PSE-RE-401【Is this your first application?】(Please tick the appropriate box.)
□ Yes
□ No

Please fill in the number of the latest Statement of Conformity Assessment.
（JET－－）
Please attach a copy of the valid Statement of Conformity Assessment.
□ Renewal
1.
Name of the Specified
Electrical Appliance orMaterials concerned
2.
Applied Standard for Testing
Description of the technical requirements by the METI Ordinance.
Appendix 1 through 9□
Appendix 12□(Standard ；3.
Applicant (manufacturer outside Japan)
Company name
Address
Representative

4.

5.

6.

7.

8.

9.

）

Position
Name
The applicant shall submit the following documents to JET for each application.
□ Type Classification (Guidelines for Type Classification on each product is available on request.)□ List of factory(s)（PSE-RE-402）□ Information for interaction（PSE-RE-403）□ Documents describing the structure, materials and performance of the product concerned（PSE-RE-701）□ Marking for Specified Electrical Appliances and Materials（PSE-RE-702）□ List of Inspection Facilities ( required for each factory )（PSE-RE-703）
Is Test Report to be issued? (Please tick the appropriate box.)□ No□ Yes ( Japanese / English version ) ( for a fee)
Listing the model name: □Necessary (Model name:） □ Not necessary
Information on the products for testing (Delivery schedule, the number of packages and other necessaryinformation)□ The products for testing (without the application documents) are to be “sent to” JET□ The products for testing are to be “carried in” JET□ The products for testing and the application documents are to be packed together and sent toJET
on/around//(Month/Day/Year) (The number of packages:)＊
Action to be taken if nonconformity on EMI is identified
If the product is found to fail in EMI test, shall the Conformity Assessment with it be stopped totally
without continuing the other items of testing ? (so that the Assessment is to be carried out anew after
the product is modified considering the result of the EMI test)□ No (The result of the Conformity Assessment is to be reported after it is completed.)□ EMI and the other testing items are to be conducted in parallel□ Yes□ EMI test first
The applicant shall submit the following documents to JET when necessary.
□ Power of Attorney (PSE-RE-404: if the application is made by an agent.)□ Application form for testing at manufacturer’s premises ( if the testing is to be carried out by
JET at the manufacturer’s premises.)□ CB test certificate and test report ( if the assessment is to be based on IECEE CB scheme.)
Agent (if applicable)
Name of Company
Address
Division / Position
Entrusted Person ( Name )TEL/FAXE-mailTEL

FAX

【PSE202401】
ANNEX to APPLICATION FORM (Form 4)

PSE-RE-402

LIST of FACTORY (FACTORIES)
Ⅰ．If it is your first application to JET
Please specify all factory (factories) relevant to the application.
Factory 1
Name offactory
Address offactory
Factory 2
Name offactory
Address offactory
Factory 3
Name offactory
Address offactory(If they are more than three, please specify them on the additional sheet(s).)Ⅱ．If any Statement of Conformity Assessment was issued to you by JET before
Is the factory for this application the same as for the previous Statement?
(Please tick the appropriate box. )Please fill in the number of the relevant Statement below.
□ Yes(It is not necessary to specify the factory here.)Statement Number（JET□ No

Please proceed to the item“Ⅰ”.

－－）【PSE202401】
ANNEX to APPLICATION FORM (Form 4)

PSE-RE-403

INFORMATION FOR INTERACTION
JET’s inquiries about this application are to be addressed to:□ Responsible person for the application□ Agent as specified in Annex to the application□ As below
Name of company
Address
Division / Position
Name of person incharge
TEL/FAXE-mailTEL

FAX

The Statement of Conformity Assessment and Test Report are to be sent to:□ Responsible person for the application□ Agent as specified in Annex to the application□ As below
Name of company
Address
Division / Position
Name of person incharge
TEL/FAXE-mailTEL

FAXThe testing fee and other expenses are to be borne by:□ Responsible person for the application□ Agent as specified in Annex to the application□ As below
Name of company
Address
Division / Position
Name of person incharge
TEL/FAXE-mailTEL

FAXThe bill is to be sent to:(If the bill for the fee and expenses is to be sent not to the same one as above)□ Responsible person for the application□ Agent as specified in Annex to the application□ As below
Name of company
Address
Division / Position
Name of person incharge
TEL/FAXE-mailTEL

FAX

【PSE202401】

What to do with the products after testing?
□ The applicant collects the tested products.
JET is to dispose of the tested products (small-sized products only). The applicant□
bears the expenses for the disposal.
□ 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□ As below
Name of company
Address
Division / Position
Name of person incharge
TEL/FAXE-mailTELFAX【PSE202401】
ANNEX to APPLICATION FORM (Form 4)

PSE-RE-404

委任状

POWER of ATTORNEY
Date:

一般財団法人電気安全環境研究所

御中To Japan Electrical Safety & Environment Technology Laboratories
申込者(Applicant)
会社名(Company name)
住 所(Address)
所属・役職(Division, Position )責任者名(Person in charge )（署名又は捺印）(Signature or seal)

私（申込者）は、次の者を代理人と定め、下記に記載する委任期間、委任内容に記載する事項を委任します。
We, the Applicant, do hereby appoint the company specified below to act on our behalf and tohandle the acts set forth below for the period specified below.
代理人(Agent)
会社名(Company name)
住 所(Address)
所属・役職(Division, Position )責任者名(Person in charge)
TEL：
E-mail：FAX：

委任期間(Validity of this power of attorney)□□□

代理人に変更があるまで(Until the agent is changed.)
期間を定める(Set the period)from（）よりuntil（
委任内容が終了するまで(Until the entrusted business is finished.)）まで

委任内容(Details of Entrustment)（例：電気用品安全法に基づく適合性同等検査の申込みに関する一切の権限）(Example.: full powers to apply for conformity
assessment under the Electrical Appliances and Materials Safety Act)（変更までの期間又は定めた期間内のお申し込みについては当該委任状の写しを必ず提出して下さい。）(While this power of attorney is valid, please submit its copy for each relevant application.)

PSE-RE-405【PSE202401】
ANNEX to APPLICATION FORM (Form 4)

Conditions for Application for Conformity Assessment
JAPAN ELECTRICAL SAFETY & ENVIRONMENT TECHNOLOGY LABORATORIESThe following conditions shall be accepted for Application for Conformity Assessment.
【Matters related to Application 】
1. All arrangements necessary for Conformity Assessment shall be made by Applicant including thefollowing:➢ All information necessary for evaluation of the Specified Electrical Appliance or Material of which
Conformity Assessment is to be carried out shall be provided to JET.
➢ JET shall be, upon request, allowed to enter the manufacturing factory and/or contact themanufacturing personnel when JET judges it necessary for Conformity Assessment.
➢ The person(s) in charge of the testing facilities, etc. at the manufacturing factory shall be, uponrequest, present in the inspection of the testing facilities.
2. The application is incomplete unless JET receives all of the following: products for testing and necessary
documents .
3. If the products for testing and the necessary documents are not delivered to JET within 6 month after theapplication form is submitted, the Application shall be considered to be withdrawn for Applicant’s reasons.
4. JET may partially outsource the product test and/or the inspection of the testing facilities for ConformityAssessment. JET informs Applicant it at the time of the reception if outsourcing is adopted.
【Matters related to Statement of Conformity Assessment 】
5. Statement of Conformity Assessment is valid only to the extent of the stated Type Classification, and thefact that the Statement of Conformity Assessment is issued cannot be made public without the validStatement of Conformity Assessment.
6. The fact that the Statement of Conformity Assessment is issued shall not be announced in such a way that
may injure JET’s reputation.
7. The fact that the Statement of Conformity Assessment is issued shall not be announced in such a way thatis not permitted by JET or that may lead to misunderstanding.
8. The use of all advertisements referring to the fact that the Statement of Conformity Assessment is issued
shall be stopped when the government gives instructions to prohibit the marking, etc.
9. The Statement of Conformity Assessment shall be used only to show the fact that the product concerned
was assessed and passed.
10. When Applicant provides Notifying Supplier in Japan, who imports the products concerned, with a copy ofthe Statement of Conformity Assessment, application shall be made to JET for issue of an official duplicateof the Statement of Conformity Assessment. If a copy of the Statement is provided to other people as asample, the Statement shall be copied entirely.
11. Request by JET, if any, shall be satisfied when the issued Statement of Conformity Assessment is referredin information media, such as documents, pamphlets and advertisements.
12. The records on complaints about Specified Electrical Appliances and Materials covered by the Statementof Conformity Assessment shall be maintained and made available to JET upon request. Besides, thefollowing steps shall be taken.
➢ Appropriate measures shall be taken on the above complaints and the products whose conformity to
the Technical Requirements of the Electrical Appliances and Materials Safety Law has turned out to bequestionable.
➢ The taken measures shall be set down in writing.
13. After Statement of Conformity Assessment is issued, JET shall be allowed to make public the registeredinformation (Applicant’s name, the name of Specified Electrical appliances and Materials and theStatement Number).
14. If JET is requested by law to disclose classified information, JET shall be allowed to disclose it after
notifying Applicant of the matters about which disclosure is requested.
【Matters related to any nonconformity identified during the Conformity Assessment】
15. If a lack of conformity is identified during the product test or the inspection of testing facilities, JET gives
notice on nonconformity (the fact that conformity cannot be achieved without appropriate improvement) asa result of the Conformity Assessment.
Any continuation of the Conformity Assessment with a proposal for the improvement shall be applied
within 40 days after the above notice. Such an application with a proposal for the improvement cannot bemade more than twice.

【PSE202401】【Matters related to products for testing】
16. Products for testing shall be delivered to Tokyo, Yokohama or Kansai Laboratory, as designated by JET.
Applicant shall be responsible for the transportation.
17. If the products for testing are with damage or a defect when delivered and JET informs Applicant about it,Applicant shall take measures to meet the situation immediately.
18. After the testing JET does not restore the tested products to their original condition, and shall not be
responsible at all for the disassembly and damage caused by the test.
Additionally, the number of packages may unavoidably increase or decrease when returning.
19. Applicant shall collect the tested products within 50 days of the completion of the test, and have noobjection to JET’s disposal of them if they are not collected within the above period. The expenses for thereturn or disposal of the tested products shall be borne by Applicant.
【Matters related to payment policy for Conformity Assessment fee】
20. Applicants are requested to prepay an assessment fee according to JET’s estimate as a general rule. If an
applicant applies to JET for the first time, JET starts testing after JET receives the prepayment. If an
applicant applies to JET not for the first time, an assessment fee may be paid after JET carries out
testing, but, as the case may be, JET may request prepayment depending on JET’s judgment.
【Confidentiality】
21. JET shall use any information obtained from the Applicant regarding the Products and their
manufacturing only for the Conformity Assessment, and shall not use any such information for otherpurposes, nor provide it to a third party without the consent of the Applicant or without a justifiablereason by the laws and regulations. Provided that the same shall not apply to any information which wasin the public domain at the time of the conclusion of this Agreement, any information which has got to be
publicly known after the conclusion of this Agreement without JET's malicious intent or negligence, or
any information which JET acquired lawfully from a third party.
【Concerning about Applications on Electronic Files】
22. Application documents stated with necessary information and signed by the person responsible for theapplication can be sent to JET via E-media. Electronic Files will be treated as the originals of theapplication documents and applications can be accepted on Electronic Files. In that case, the originals of
the application documents must be kept at the applicant side.
End of document

【PSE202401】
ANNEX to APPLICATION FORM（共通）

PSE-RE-701

試験品の構造、材質及び性能の概要
The Outline of Products for testing : Structure, Material and Performance１．

構造の概要 The Outline of Structure（製品のモデル名、並びに当該製品の機能、構造、動作原理などの概要を記載して下さい）(Please state the model name of the product as well as the outline of its function, structure and operating
principles and so on.)２．

材質 Material（外郭及び主要部品の材料（変圧器、電動機などは「巻線の絶縁の種類」の根拠となる絶縁物名）を記載して下さい）(Please state the material of the outer case and main components (as for transformers, motors and so on, the nameof the insulator by which “winding insulation class” is to be judged).)３．

性能又は定格 Performance (Ratings)（性能、電圧・消費電力などの電気定格等、「型式の区分」が判断できる内容を記載して下さい）(Please state the factors by which “Type Classification” can be judged, such as performance, the ratings for voltage,
power consumption and so on.)４．

技術的情報 Technical information（試験品の写真・図面、構成部品一覧表、回路図、取扱説明書、その他試験を実施するために必要な資料）(Please provide photos, drawings, a list of components, circuit diagrams, an instruction manual and otherinformation necessary for testing. )【PSE202401】
ANNEX to APPLICATION FORM（共通）

PSE-RE-702

特定電気用品の表示
Marking for Specified Electrical Appliances and Materials
１．

特定電気用品への表示 Markings on "Specified Electrical Appliances and Materials"

２．

荷札又は包装容器への表示 Markings on the Labels, Tags or Packaging（電線、ヒューズ、配線器具、変圧器等の特例）(Special cases for cables, cords, wiring devices, transformers and so on.)３．

届出事業者の略称又は登録商標 Notifying Supplier’s abbreviation or registered trademark（電気用品安全法施行規則第 17 条の規定により表示すべき届出事業者の氏名又は名称について、略称又は登録商標を用いる場合、経済産業大臣の承認を受けた略称、又は経済産業大臣に届け出た登録商標に限ります）
If the Notified Supplier is to use its abbreviation or registered trademark based on the provision at Article 17 of
Enforcing Rules for Electrical Appliances and Materials Safety Act, the abbreviation must be approved by theMinister of Economy, Trade and Industry and Notice on the registered trademark must be submitted to theMinister of Economy, Trade and Industry.

略称表示承認日
The Date ofapproval fortheabbreviation

年月日Year Month Day

登録商標
表示届出日
The Date ofNotice on theregisteredtrademark年
月日Year Month Day

【PSE202401】

PSE Scheme Operational and Regulatory Documents

OD-JETPSE0008

特定検査設備調査準備のためのご質問
Questionnaire for scheduling the Authorized Inspection Facilities Field Verification

受付番号：
Project No.

1

製造工場の名称及び所在地（JET記載欄）(To be filled in by JET)

Manufacturer’s registered name and factory address

工場名Name
所在地Address
2工場の連絡者 Contact person in factorya. 連絡者名 Name
所属・役職

Department / Position

TELFAX
E-mailb.

副連絡者名Name of deputy contact person in factory

所属・役職

Department / Position

TELFAX
E-mail3

工場までの道順（最寄り駅、空港などの情報と工場周辺地図のコピーを添付して下さい。
）
Direction for reaching the factory (Please make sure the nearest railway station, the airport,and attach a copy of local map.)4

申込者又はその代理人 Applicant or Agent
氏名Name in block
署名
Signature

日付Date※海外製造工場の検査設備確認料につきましては、JET が委託した検査機関より製造工場様へご請求された場合は、委託検査機関へお支払いをお願いします。
In the case a certified testing laboratory authorized to conduct factory inspection at yourfactory site by JET asks you to pay the inspection fee to the laboratory, please do so.

【PSE202401】

様式第七 Form 7

出張試験申込書
Application for Testing based on Procedures of Testing at Manufacturers’ Premises

受付番号：Project No.

一般財団法人電気安全環境研究所（JET記載欄）(To be filled in by JET)

御中To Japan Electrical Safety & Environment Technology Laboratories

下記の特定電気用品について、出張試験を受けたいので申し込みます。
Hereby we apply for testing of the products stated hereunder at the manufacturer’s premises.

記1.

申込者（届出事業者／海外製造事業者）Applicant / (manufacturer outside Japan)
会社名Company name

住Address

所

責任者名

The person responsible for the application（署名又は捺印）(Signature or seal)

所属・役職

責任者の住所Division / Managerial position

Address of the responsible person (If different from the above one of the Company)(上記と異なる場合)

TEL：
E-mailFAX：2.

特定電気用品名：Name of Specified Electrical Appliances and Materials

3.

型

4.

申込

理

由：Reason for this Application

5.

試験場

所：Place for the Testing

式：Models of the Product