REQUEST FOR SPECIAL INSPECTION AND/OR US FIELD EVALUATION SERVICE EQUIPMENT INTENDED FOR USE IN ORDINARY LOCATIONS ONLY Client Number: Date: File Number: (CSA Use Only) SUBMITTOR (Company Name and Address) SEPARATE BILLING ADDRESS (This cannot be a 3rd Party) Note: Click on gray cells to enter information electronically SUBMITTOR CONTACT PERSON Name: Phone # Fax #: Mobile #: E-Mail: Purchase Order: CONTACT PERSON AT LOCATION OF INSPECTION (Name and Phone Number) Name: Phone #: E-Mail: LOCATION OF INSPECTION (enter X) X Same as Submittor CSA Laboratory Different Location (Please include company name, street address, city/town and, province or state) DESCRIPTION OF PRODUCT(S) FOR INSPECTION (Ordinary Locations Only) Please include model, electrical rating, type of equipment, number of units, and if intended for Canada or the US Is equipment NEW or USED FOR CANADA NOTES: ***** Minimum 24 Hour Cancellation Policy***** Cancellations with less than 24 hours notice may be levied a cancellation fee of up to $200.00 in addition to any travel costs incurred. -- Upon the successful conclusion of the equipment evaluation, units found in compliance with the relevant requirements are marked with the Special Inspection and/or US Field Evaluation label. Alterations noted during the inspection may be performed during the inspection. Additional time and/or subsequent visit(s), if required, will be subject to additional charges. -- The Special Inspection and US Field Evaluation services are not equivalent to product certification and only covers on-site approvals of one-of-akind installations, limited run or custom products where certification is not a practical option. If product certification is more appropriate for your products, you will be notified of that fact. DQD 502.22 Rev. 2012-11-26 © The Canadian Standards Association. All rights reserved.