Points while preparing application documents【PSE201905】

様式第五（第2号検査／国内製造事業者又は海外製造事業者用）

Form 5適合証明書又は適合同等証明書の副本申込書
Application for Duplication of Statement of 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

既に交付された（適合証明書／適合同等証明書）の副本の交付を受けたいので、次のとおり申し込みます。
We hereby apply for the official duplicate of the “Statement of Conformity Assessment” which was already issued.

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
Please fill in the applicant company name and address based on JET issued PSE certificates.

住Address

所The person responsible for the application must be the applicant employee with the authorizationfrom the applicant company, but the person is not necessary the company representative.

責任者名The person responsible for the application
Either the authentic signature by the person responsible for the applicationor the seal of that person(not of the company) is necessary.

所属・役職
責任者の住所（署名又は捺印）(Signature or seal)

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-mail2.

FAX：

Please enter the name of Specified Electrical Appliance or Material
which is stated in the “Statement of Conformity Assessment”

特定電気用品名：

Name of Specified Electrical Appliances and Materials3.

証明書番号：
Statement Number

4.

副本交付部数：部

The number of official duplicates to be issued:

Please state the cert. No. of the “Statement of ConformityAssessment”.
In case there are several “Statement of Conformity Assessment” needthe duplicates, please attach a list stating the cert. numbers and thenames of the Specified Electrical Appliances and Materials.

Points while preparing application documents【PSE201905】
PSE-RE-602

申込書別紙（様式第五用）

送付先等確認用紙(連絡先が申込責任者と異なる場合)

Information for Interaction(if the contact person is not the person responsible for the application)

受付番号Project No.：（JET記載欄 To be filled in by JET）

この申込みに係る連絡・送付及び請求先は、次のとおりです。
Contact information for this application is as follows.

連絡先：Point of Contact
会社名Name of company
住 所Address
所属・役職
Division / Position

担当者名
Name in charge
TELFAX

E-mail

注：連絡先は、申込者と同一法人のご担当者又は代理人（委任状が必要となります）に限ります。
The contact person shall be a member of the applicant or its properly authorized agent(the valid “POWER of ATTORNEY: PSE-RE-404” is necessary for the authorization).

□

クレジット決済を希望する。
Credit Card settlement（発行手数料のお支払いにクレジット決済を希望する場合はチェックをして下さい。
担当より、折り返し、ご説明を致します。）（In case you hope to use the credit card to pay the issuance fee, please take a check.
JET staff will explain the details later.）

適合証明書又は適合同等証明書の副本申込書用
Annex to Application (Form 5) for Duplication of Statement of Conformity Assessment

Points while preparing application documents【PSE201905】
ANNEX to APPLICATION FORM

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 )Please enter the address “in full”, including the postal code.(Please do soin all following “address” boxes).

Either the authentic signature by the person responsible for the（署名又は捺印）application or the seal of that person(not of the company) is necessary.
(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.)