Service Requisition Form for REACH (REACH服务申请表).doc

Service Requisition Form for REACH (REACH服務申請表) Form No. Applicant’s Company Name 公司名稱: Official Use Only Address 地址: Job No. Contact Person 聯絡人: Tel電話號碼: A/C No. E-mail電郵: Fax傳真號碼: Company Name Address shown on Test Report (if different from the Co. Name above) 報告頁首之公司名稱及地址 (若同上，則不用填寫) : Sample Description / Item Name樣品名稱: Item / Ref. / Model / Style No.樣品型號*: No. of Sample Submitted樣品數量: Goods Exported to產品運往: Europe Country of Origin 原產地: Supplier 供應商 / Vendor 賣家/ Manufacturer 製造商*: Buyer Name買家: Test(s) Required: (Please tick appropriate boxes) 測試項目名稱 (請在適當空格內 “”) SVHC Screening Test REACH Formulation Assessment REACH Restricted Substance (Annex XVII) Entry : _________ Safety Data Sheet (SDS) - EU Others: For details of the test method used, please refer to the information on Intertek website. /resources/jobrequestforms/?lang=en Select Country: Hong Kong and click ‘Go’ button. Service Required服務要求: Regular普通 Express 快 (40% Surcharge 附加費) Shuttle 特快 (100% Surcharge 附加費) Electronic report/invoice only電子報告及發票: Yes 是 Return Sample退回樣品: Yes需要 No不需要 Is this a retest是否重試: Yes是 No否 If Yes, Please state previous report no. 如是請填上舊報告的號碼: We request for the above tests and agree that all testing will be carried out subject to INTERTEK TESTING SERVICES HONG KONG LTD’s scale of charges as set forth in their latest price list of which we have seen a copy and upon and subject to the terms and conditions set out hereon and overleaf. Date日期: 公司蓋章及代表簽名: Authorized Signature And Company Chop of the Applicant (P.T.O. for terms and conditions) * Please check the appropriate checkbox. TEST REQUISITION FORM without company chop will NOT be valid. Client should retain a copy of the requisition form for own reference and present the same for collection of test report in our office. No comment may be given for some of the test items if related standard or specification is not available. Pick-up a