Form EAC001C Page 1 of 4

U.S. Election Assistance Commission

Manufacturer Registration Application OMB Control # 3265-0024

Expires: 9/30/2025

1. Manufacturer Information

Legal Name of Business: 

Address of Business:

City: State: ZIP Code:

Organization Type: Corporation Partnership Sole Proprietor Other:

(please explain)

Names of Officers, Board of 

Directors, and all Partners:

Name of Individualor Entity

with Controlling Ownership 

in the Manufacturer:

2. Management Representative

First Name: Title:

Last Name: Middle Initial:

Address:

City: State: ZIP Code:

Email: PhoneNumber:

3. Technical Representative

First Name: Title:

Last Name: Middle Initial:

Address:

City: State: ZIP Code:

Email: PhoneNumber:
Form EAC001C Page 2 of 4

4. Brieflydescribeyourquality system (e.g. ISO9001). Provideyourwrittenpoliciessupporting 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 policiessupporting 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:

Tomaintaina voting systemcertificationundertheElectionAssistance Commission (EAC)program,the 

manufacturer must agree to to all provisions as stated in the Manufacturer Agreements section in the currently 

effective Testing and Certification Program Manual.

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. ManufacturerInformation.

Names of Officers and/or Board of Directors and/or 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 2.2 of the Manual. 

3. Technical Representative.

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

2.2 of the Manual.

4-7

Providethe informationlisted and attachto yoursubmissionthe written documentation required by Section 2.2 of 

the Manual.

8. 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. Thisinformationwill be used solely to administerthe EACTesting and Certification Program. This programis voluntary, 

however, individualswhowish to participatemustmeetthe requirementsoftheProgram. Thisinformationwill bemade public 

consistent with therequirements ofthe Freedom ofInformationAct,theTrade SecretsAct, 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 timeforreviewing the instructions, gathering information, and completing 

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

Assistance Commission, 633 3rd Street NW Suite 200, Washington DC 20001. Notwithstanding any other provisionof law, no 

person isrequired to respond to, norshall any person be subject to a penalty forfailure to respond to, or comply with, a 

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

displays a currently valid OMB Control Number.