TEST REQUEST FORM-HARDLINES AND ELECTRONIC PRODUCTS
Please type or print in BLOCK LETTERS (*Mandatory Field - Must Fill In)
Hayneedle (JDE# 202736) formerly Netshops, Inc.
Company Submitting For
Submitter (Company)
Address
City
Phone
*E-mail Address
Purchase Order No.
Submitter Contact
State
Zip
Invoice Recipient (if different than above)
Note: Vendor is responsible for paying for transit testing
unless otherwise indicated on the Test Request Form.
CPSIA General Conformity Certificate Please indicate which GCC, if any, below – there is a fee associated with each one of these selections
BY REQUEST ONLY
Certificate of Compliance GCC
Review GCC
Product Engineering Solutions GCC
Please provide name, full mailing address, e-mail address and telephone number of the person maintaining test records in support of the certification.
(Remark: Manufacture Information is required for CPSIA’s General
Name of Manufacturer:
Conformity Certificate)
Mailing Address/ Tel No.:
Date of Manufacture
(MM/DD/YY):
Place of Manufacture (City/Province/Country):
SAMPLE INFORMATION:
Where these samples gathered through a sample collection program?
Yes
Sample Description:
SKU/Style No.:
Lot Date Code.:
Item No.:
Country of Origin:
Return Sample (shipping and handling charges apply)
SERVICE REQUIRED*:
(Check One)
Regular (7 - 10 business days)
Same Business Day (sample receipt by 10:30 a.m.)**
Next Business Day from receipt of sample**
*Special requests or unique testing may require additional time
TESTS AND OTHER SERVICES:
(Check Applicable Box(es))
Enter Protocol #
No. of Cartons:
No. of Samples:
Manufacturer:
Country of Distribution:
Next 2 Business Days from receipt of sample**
Next 3 Business Days from receipt of sample**
Next 5 Business Days from receipt of sample**
**Additional Charges Apply
Quotation Requested Prior to Initiation
16 CFR 1303 Lead Content (Painted items only )
BVCPS Protocol Testing
(An Audit to Compliance and Industry Standards)
Protocol Star Level:
Level 1
Level 2
No
CONEG (Packaging Material Regulation)
NIOSH 9100 Wipe Test Modified
Level 3
Test in accordance with Quotation #
FDA Extractable Lead & Cadmium (6 identical items needed)
Long Report for Customs
Other Tests
Comparison to National Brand
Retest (applicable only if 6 months or less), please provide the
previous Technical Report number ___________________
Customer Complaint – please provide details
Short Report
CA Health & Safety Code 25249.5 (Prop. 65 lead/cadmium)
(Ceramic or Colored Glass - 6 identical items needed; if greater than or equal to 2,000
identical items distributed in California - 12 identical items needed)
California Extractable Lead and Cadmium by Total Immersion
SGCD Extractable Lead & Cadmium (Lip &Rim)
ISTA 6A -- FedEx – if the package is a small parcel;
e.g. less than or equal to:
• 150 pounds
• 119 inches in length (longest side)
• 165 inches in length + girth {L+(2xH)+(2xW)}
California Prop 65 Testing on Rim – ASTM C927
(6 identical items needed – Ceramic or Glass)
ISTA 3B -- if the package is an LTL (motor freight) shipment direct
to consumer and it is greater than any of the above measurements
FDA Food Simulating Solvent Extractives
Please specify plastic type (Polyethylene, Polypropylene, Copolymer,
Melamine, Polycarbonate) _________________________________
CA Prop 65 Raw Materials for Decorated Tableware
(Decals or Paints)
Remarks
Authorized Signature:
Document1
Date:
Page 1 of 2
Revised: October 2015