Exhibit A – GlobalPlatform Qualification Request Form
For Laboratory

New Laboratory
Laboratory Update (please provide Laboratory identification and updated data only)

Laboratory Identification
Company Name:
Company Registration
No:
Business Address:
City:

State/Prov.:

Country:

Postal Code:Facility Details:
Address if not Company Address:
Description:
Qualification Number of the GP Qualified Test Tool(s):Certificate of Accomplishment of GP Test Suite Training:
Certificate of Accomplishment of GP Specification Training:
Identify current lab certifications (please provide corresponding
certificates and documentation):- ISO 17025 Certification- EMVCo Certification- Common Criteria Certification- FIPS Certification- PCI Qualified Certification- Other Please check here if you do not want a Listing for this Qualification to appear on theGlobalPlatform web site.

© GlobalPlatform 2014-2021

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General Laboratory and Facility Information
Please identify any superior or subordinate business
relationships, e.g., with a parent company or subsidiaries
Is there any conflict of interest in regard to Laboratory
ownership and your vendor customers?
Provide an organizational chart for your Laboratory

Please attachDoes your Laboratory have audited financial reports and theequivalent of a Dun & Bradstreet report?

Please attach, if available

Does your Laboratory have adequate insurance covering thecompany and each facility for which accreditation is beingsought?
Is your Laboratory currently a party to a contract with
GlobalPlatform or any of its Members? Please explain.
Laboratory Background and Experience
Provide an Executive and Financial Summary of the Laboratory
for the last 3 years

Please Attach

Describe the Laboratory’s technical expertise, including
experience with GP Specifications, to the extent relevant to theFacility and its operations
Provide a brief description of your Laboratory’s background, tothe extent relevant to the Facility and its operations
Laboratory Contact Information
Laboratory Officer:
Name:

Title:

Direct Telephone:

E-mail:Location:

Fax:

Contact for Legal Notices:
Name:

Title:

Direct Telephone:

E-mail:Location:

Fax:

Primary Contact for all Communication regarding Evaluations
Name:

Title:

Direct Telephone:

E-mail:Location:

Fax:

Primary Contact for all Financial Communications and Invoices
Name:

Title:

Direct Telephone:

E-mail:Location:© GlobalPlatform 2014-2021

Fax:

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By signing this Qualification Request, I acknowledge, agree and certify, by and on behalf of thecompany identified above ("Company"), that (i) all capitalized terms used but not defined herein havethe meanings ascribed to them in the Qualification and Listing Agreement between Company andGlobalPlatform, Inc., as amended (the "QLA"), (ii) Qualification of the Facility identified above, ifobtained, and the procedures for obtaining Qualification, are subject to the terms, conditions andrestrictions of the QLA, the GP GlobalPlatform Self-Testing and Product Qualification Process
requirements, and any additional terms set forth in the corresponding Qualification Letter, including
without limitation, payment of applicable Fees and termination or revocation in accordance with theQLA, (iii) Qualification is limited to the specific Facility identified in the corresponding Qualification
Letter, (iv) the Facility satisfies all prerequisites for the corresponding Qualification, (v) all information
provided to GlobalPlatform, Inc. by Company regarding the above Facility is accurate and completeand (vi) I have been duly authorized by Company to execute and submit this Qualification Request.

Company Officer Signature Company Officer
Name:

Date Title:

Received by GlobalPlatform, Inc.
GlobalPlatform, Inc. Signature Date Name:
Title:© GlobalPlatform 2014-2021

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