Points while preparing application documents【PSE201811】

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 must be the applicant employee with theauthorization from the applicant company, but the person is not necessary thecompany representative.
Either the authentic signature by the person responsible for the application or the sealof the person is necessary.(Document only with company seal cannot be accepted.)
責任者名は、申込者（届出事業者）の代表者名である必要はありませんが、同一法人の中で本申込みについて権限を与えられた方の氏名を記入して下さい。責任者の方の自筆署
名又は捺印（会社印は認められません。）が必要です。

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 attachment

3. 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Points while preparing application documents【PSE201811】
PSE-RE-401

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

If any “Statement of Conformity Assessment” was issued by JET for you in the past, please make sure to fill in thenumber of the latest “Statement”.
過去に、ＪＥＴにて「適合証明書」を交付されている場合には、最新の「証明書番号」を必ず記入して下さい。

□ Renewal

Please attach a copy of the valid Statement of Conformity Assessment.

If you apply for “renewal”, please put a tick only here.
Please attach a copy of the “Statement of Conformity Assessment” for which the “Renewal” is applied so that JET may
verify the product “Type Classification” is the same as of the valid “Statement of Conformity Assessment”. Please notethat application without a copy of “Statement of Conformity Assessment” cannot be accepted for “Renewal”.
Application for Renewal can be done within 6 months before the valid date of the certificate, and the application must
be done when the certificate goes invalid in 3 months.
「継続」申込の場合には、この箇所のみチェックを入れて下さい。
有効期限の残っている「適合証明書」と同一の「型式の区分」であることを確認させて頂くため「継続」申込を行う「適合証明書」のコピーを添付して下さい。
「適合証明書」のコピーの添付がない場合には、「継続」申込とは取り扱えませんので、注意して下さい。
「継続」申込の場合には、「適合証明書」の有効期限の切れる６ヶ月前より受付可能です。なお、有効期限の切れる
３ヶ月前までには、受付を完了して下さい。

1.
2.

Name of the Specified
Electrical Appliance orMaterials concerned
Applied Standard for Testing

Please state the Name of the Appliances or Materials according to “TypeClassification”.
電気用品名は、個々の「型式の区分」の電気用品名に合致させて記入して下さい。

Description of the technical requirements by the METI Ordinance.
Appendix 1 through 9□
Appendix 12□(Standard ； Tick off one of □ and state the test standard here ）Please fill in this blank referring to materials on the way to state the applied Standard for Testing. Please note that “J standard
numbers (including those for “Noise strength” and “Remote control mechanism”)” and their “year code” are necessary if theapplication is by Appendix 12.
Example (1): Appendix 8 + Appendix 10
Example (2): Appendix 12 J60335-1(H27), J60335-2-29(H27) and J55014-1(H27)
適用試験基準の記載方法の資料を参考にして記載して下さい。また、別表第十二でのお申込の場合は、「Ｊ規格番号（「雑音の強さ」及
び「遠隔操作機構」に該当するものを含む）」及び「適用年号」の記載も必要ですので注意して下さい。
記載例①：別表第八＋別表第十
記載例②：別表第十二 J60335-1(H27)、 J60335-2-29(H27)及び J55014-1(H27)

3.

Applicant (manufacturer outside Japan)
Company name
Address
Representative

4.

5.

6.

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 necessary
information)□ 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:)＊

Points while preparing application documents【PSE201811】
7.

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.)□ Yes□ EMI test first□ EMI and the other testing items are to be conducted in parallel(1) If you select “EMI test first”, the other items of testing will not be started until EMI test is completed, so testing may take longtime. Your understanding is requested.
(2) If you select “EMI and the other testing items are to be conducted in parallel”, EMI and the other items of testing areconducted at the same time, so, even if the product fails in EMI test , the fees for the testing conducted until then will becharged.
①「雑音試験優先」を希望される場合は、雑音の強さ試験が終了するまでその他の試験を着手しません。終了までの期間が長くなることをご了承下さい。
②「雑音試験とその他試験を同時実施」を希望される場合は、雑音の強さ試験と並行してその他の試験を実施します。雑音の強さ試験が不適合となった場合、それまでに実施した試験費用を頂戴する場合があります。

8.

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.)
9. Agent (if applicable)
Name of Company
Please fill in this blank if the application is made by an agent.
Address
Division / Position
Entrusted Person ( Name )TEL/FAXE-mailNote) “Power of Attorney (PSE-RE-404)” must be submitted.
代理人を立ててお申込み頂く場合には記入が必要です。
注）「PSE-RE-404」の「委任状」の提出が必要になります。

TEL

FAX

Points while preparing application documents【PSE201811】
PSE-RE-402

ANNEX to APPLICATION FORM (Form 4)

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”.

If the factory information is same as the PSE certificate issued by JET, please state the latest certificate number.
過去にＪＥＴに申込を行い「適合同等証明書」を取得している場合には、最新の「適合同等証明書」の「証明書番号」を記載して下さい。

Points while preparing application documents【PSE201811】
PSE-RE-403

ANNEX to APPLICATION FORM (Form 4)

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 in
chargeTEL/FAXE-mailTEL

FAXThe 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 in
chargeTEL/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 in
chargeTEL/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 in
chargeTEL/FAXE-mailTEL

FAX

Points while preparing application documents【PSE201811】
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 in
chargeTEL/FAXE-mailTEL

FAX

JET accepts requests to dispose of tested products if they are small-sized ones, such as components and materials, for a fee(JPY3,000 for a case). If it is not possible to dispose of the tested products, please tick either “The applicant collects the tested
products” or “The tested products are to be sent to (with payment to be made by the addressee):”
ＪＥＴでの廃棄を希望される場合には、部品、材料等の小型のものに限り、有料（１件当たり３，０００円）で申し受けます。
なお、廃棄できない試験サンプルについては、「引き取り」又は「着払い返送」にチェックを入れて下さい。

Points while preparing application documents【PSE201811】
PSE-RE-404

ANNEX to APPLICATION FORM (Form 4)

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)

Either the authentic signature by the person responsible for the application or the seal of that
person (not of the company) is necessary.
責任者の方の自筆署名又は捺印（会社印は認められません。）が必要です。

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

Regarding the Validity of this power of attorney, please make sure to tick one of the boxes.
If “Set the period”, please make sure to specify the period.
「委任期間」については、必ずいずれかの□にチェックを入れ下さい。
なお、期間を定めて委任する場合には、委任期間を必ず記入して下さい。

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 applicati on.)

Points while preparing application documents【PSE201811】
PSE-RE-405

ANNEX to APPLICATION FORM (Form 4)

It is not necessary to submit this paper, but please make sure to read and accept these conditions.
承諾事項の提出は不要ですが、必ずお読みいただきますようお願いいたします。

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 the
manufacturing 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 Conformity
Assessment. 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 of
the 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) as
a 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.

Points while preparing application documents【PSE201811】【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.
19. Applicant shall collect the tested products within 50 days of the completion of the test, and have no
objection to JET’s disposal of them if they are not collected within the above period. The expenses for the
return 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

Points while preparing application documents【PSE201811】
PSE-RE-701

ANNEX to APPLICATION FORM（共通）

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. )Points while preparing application documents【PSE201811】
PSE-RE-702

ANNEX to APPLICATION FORM（共通）

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.)Regarding “Electrical Appliances and Materials” for which marking on the Labels, Tags or Packaging is permitted tomeet the marking requirements (Appendix 5) under Enforcing Rules Article 17 (Method of marking), please specify
the marking contents.
Besides, regarding single items of components of from Technical Requirements Appendix 1 through Appendix 6
which are regarded as “Electrical Appliances and Materials” and for which “marking” is made on “Labels”, “Tags” or“Packaging” and marking on “the product itself” “can be omitted partially”, please specify the marking contents on“Labels”, “Tags” or “Packaging”.
施行規則第１７条（表示の方式）に係る表示義務内容（別表第五：電気用品の表示の方法）として、「荷札」又は「包装容器」
への表示が認められている「電気用品」については、表示内容を明記して下さい。
また、技術基準別表第一から別表第六までの部品単品で「電気用品」の対象となるものであって、「荷札」又は「包装容器」
への「表示」を行うものにあっては、「製品本体」への表示を「一部省略することができる」電気用品もあることから、「荷札」又は「包装容器」へ表示する場合には、表示内容を明記して下さい。

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 the
Minister of Economy, Trade and Industry and Notice on the registered trademark must be submitted to the
Minister of Economy, Trade and Industry.

略称表示
承認日
The Date of
approval fortheabbreviation

年月日Year Monty Day

登録商標
表示届出日
The Date of
Notice on theregisteredtrademark年
月日Year Monty Day

Points while preparing application documents【PSE201811】
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
Address2

工場の連絡者 Contact person in factorya. 連絡者名 Name
Please specify the “name”, “Department / Post” and “Contact address”, etc. of the persons who will deal withthe on-site verification of inspection facilities. .
検査設備の現地確認の際に、ご対応いただける方の「氏名」、「所属・役職」及び「連絡先」等を記入して下さい。

所属・役職 Department / Position
TEL
FAX
E-mailb.

副連絡者名 Name of deputy contact person in factory
所属・役職 Department / Position
TEL
FAX
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 his representative
氏名
Name in block

署名

日付

SignatureDate※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。

製造工場様

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.

Points while preparing application documents【PSE201811】
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（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