Form EAC001C Page 1 of 4

U.S. Election Assistance Commission

Manufacturer Registration Application OMB Control # 3265-0004

1. Manufacturer Information

ZIP Code:

Partnership Other 

Name of Individual or Entity with

Controlling Ownership in the

Manufacturer:

2. Management Representative

First Name: Title:

Last Name: Middle Initial:

Address:

City: State:

ZIP Code: Email:

PhoneNumber: FAX Number:

3. Technical Representative

First Name: Title:

Last Name: Middle Initial:

Address:

City: State:

ZIP Code: Email:

PhoneNumber: FAX Number:

Legal Name of Business:

Address of Business:

City:

Organization Type: Corporation

State:

Sole Proprietorship

Names of Officers, Board of Directors, and

all Partners:
Form EAC001C Page 2 of 4

4. Briefly describe your quality system (e.g. ISO9001). Provide yourwritten policiessupporting this

description as a part of this application :

5. Briefly describe your internal requirements for managing change control/version control for both

hardware/firmware and software. Provide your written policies supporting this description as part of

this application :

6. Briefly describe your document retention requirements . Provide your written policies supporting

this description as part of this application :

7. List the name, address, city, state/province, country, postal code, and phone number for all 

 facilities used by your company to manufacture your voting system product, and the name, 

 title, address, email address, and phone number for a person at each facility:
Form EAC001C Page 3 of 4

8. Manufacturer Certification Agreement:

To maintain a voting systemcertification underthe ElectionAssistance Commission (EAC) program,the

manufacturer must agreeto:

1. Represent a voting system as certified only when it is authorized by the EAC and consistent with the

procedures and requirements ofthe Testing and Certification Program Manual (the Manual).

2. Produce and permanently affix an EAC certification label to all production units of the certified system.

3. Notify the EAC of changesto any system previously certified by the EAC pursuantto the requirements of

the Manual.

4. Permit an EAC representative to verify manufacturer quality control by coordinating with EAC efforts to test

and review fielded voting systems consistent with Section 8.6 of theManual.

5. Permit an EAC representative to verify manufacturer quality control by conducting periodic inspections of

manufacturing facilities consistent with Chapter 8 of the Manual.

6. Cooperate with any EAC inquiries and investigationsinto a certified system's compliance with voting system

standards or the procedural requirements of the Manual.

7. Report to the Program Director any known malfunction of a voting system holding a current EAC

Certification. A malfunction is defined as a failure of the voting system, not caused by operator or

administrative error, which causes the system to fail or otherwise not operate as designed.

8. Certify that the manufacturer is not barred or otherwise prohibited by statute regulation or ruling from

doing business in the United States.

9. Adhere to all procedural requirements of theManual.

Signature (handwritten or digital)

Title:

Date:

EAC Use Only

Manufacturer's 

Designation:

Notes:
Form EAC001C Page 4 of 4

Instructions:

This form provides for the registration of voting system manufacturers. Registration is the initial required step in the EAC 

Voting System Certification Program. This form is prescribed by Section 2.4 of the Manual. For more information on 

registration requirements please see Section 2.4 of the Manual.

This form is generally self-explanatory however the numbers and the instructions below correspond to the numbered sections 

of the form.

1. Manufacturer Information.

Names of Officers and/or Board of Directors and/or any and all Partners: Ensure that all individuals are identified by 

name, and title.

Name of Individual or Entity with Controlling Ownership in the Manufacturer: Ensure that the controlling individual is 

properly named and an address is provided.

2. Management Representative.

Please provide the name and information requested for the designated Manufacturer Representative pursuant to Section 2.3 of 

the Manual.

3. Technical Representative.

Please provide the name and information requested for the designated Technical Representative pursuant to Section 2.3 of the

Manual.

4, 5 and 6

Provide the information listed and attach to your submission the written documentation required by Section 2.3.1 ofthe 

Manual.

7. Manufacturer Certification Agreement

Manufacturers are required to take or abstain from certain actions consistent with the certification program. Your concurrence

to these requirements is signified by affixing the signature of the manufacturer representative.

This information is required for the EAC to provide for the certification of voting systems as required by 42 U.S.C. Section 

15371. Thisinformation will be used solely to administerthe EAC Testing and Certification Program. This programis voluntary, 

however, individuals who wish to participatemustmeetthe requirements ofthe Program. Thisinformation will bemade public 

consistent with the requirements ofthe Freedomof Information Act,the Trade Secrets Act, and any other applicable Federal 

law or regulation. Public reporting burden for this collection of information is estimated to average about 9.75 hours for 

completion ofthisform. This estimate includesthe time forreviewing the instructions, gathering information and completing

the form. Send comments regarding this burden estimate to the Testing and Certification Program Director, Election 

Assistance Commission, 1335 East West Highway, Suite 4300, Silver Spring, MD 20910. Notwithstanding any other provision of

law, no person is required to respond to, norshall any person be subject to a penalty forfailure to respond to, or comply with,

a collection ofinformation subjectto the requirements ofthe Paperwork ReductionAct, unlessthat collection of information

displays a currently valid OMB Control Number.