MED Application

Dear Sirs,
please send us the below information to be used in preparation of our offer for product’s conformity assessment/inspection.
Completion of the application does not mean an obligation to use our services, and no fee will be charged thereupon. Information contained in the application will be treated as confidential.

Notification Body for certification:
Name: Polish Register of Shipping
VAT no: 584-030-44-72
Phone: (+48) 58 75 11 273
E-mail: dc@prs.pl
Adress: al. gen. Józefa Hallera 126, 80-416 Gdańsk
Accreditation number: AC 114

Information on certification requirements as well as Applicants’ rights and responsibilities is available at www.prs.pl

Application *concerning the performance of product certification/conformity assessment/inspectionconcerning the extension of the scope of the certificateconcerning the renewal of the certificate

Applicant *

Street *

Town *

Zip code *

Country *

Applicant status *Manufacturer - means any natural or legal person who manufactures PPE or has it designed or manufactured, and markets it under his name or trademarkBrand manufacturer - a particular group of manufacturers, a physical or legal person who sells a product under his name or trademark designed and/or manufactured by the actual manufacturer, identical in design and technology to the product introduced into the sales by the actual producerAuthorised representative - means any natural or legal person established within the Union who has received a written mandate from a manufacturer to act on his behalf in relation to specified tasks

Registered in (please specify register name and its location) *

Under the entry (please specify assigned registry number) *

VAT No.: *

Share capital (if applicable to form of business)

Is the Manufacturer different than the Applicant? *YesNo

Manufacturer (if other than Applicant) *

Street *

Town *

Zip code *

Country *

Registered in (please specify register name and its location) *

Under the entry (please specify assigned registry number) *

VAT No.: *

Share capital (if applicable to form of business)

Product to be assessed for conformity/inspection with EU Directives (please specify a name of the product – its proper name, the product type, etc., according to the product label. Given product name will be binding on each stage of the conformity assessment) *

EU Directive or UE Regulation: *MED

Module(s) *

Readiness for assessment *

Year

Month

Day

Number of employees involved in certification process general *

Number of employees involved in certification process in design *

Number of employees involved in certification process in production *

Number of employees involved in certification process in quality control *

List of standards and regulations applicable to the product *

Approvals, certificates held by Applicant/Manufacturer *

Applicant’s declarations *I confirm that I have acknowledged and understood general requirements concerning product certification system/conformity assessment/inspection.I confirm that an application for conformity assessment was not placed with another notified body.I undertake to comply with all requirements regarding application for product certification/ conformity assessment/inspection.I undertake to supply complete technical documentation of the product and all information indispensable for assessment of the product/inspection.I confirm that the product presented for certification was not a subject of cooperation between the Applicant and Polish Register of Shipping (e.g. at designing stage).

Has the Applicant received any claims concerning the products covered by the scope of the certificate within its validity period (it concerns extension, prolongation, recertification)? *YesNoN/A

Does the Applicant have any connections (e.g. Business liaisons) with the provider of tests reports which are enclosed to this Application (if applicable)?YesNoN/A

Applicant’s authorized contact person

The Applicant shall familiarize the person authorized for contact with the Information Clause below.

First name *

Last name *

Position *

Email *

Phone number *

Additional recipient (dedicated contact person at PRS S.A.)

Part for legal entityI agree to the use by PRS S.A. seated in Gdansk of telecommunications terminal equipment and automatic calling systems (e.g. telephone, e-mail), which we are a user of, for the purposes of direct marketing, in accordance with art. 172 of Telecommunications law and sending commercial information.

Part for natural persons (also one-man businesses): Information on the right to withdraw consentConsent No. 1 I agree to the processing of my personal data provided in this form by PRS S.A. seated in Gdansk for marketing purposes.Consent No. 2 I agree to the use by PRS S.A. seated in Gdańsk of automatic calling systems or telecommunications terminal equipment, which I am a user of, for the purposes of direct marketing, in accordance with art. 172 of Telecommunications law.Consent No. 3 I agree to receive business information by electronic means from PRS S.A. seated in Gdańsk, in accordance with art. 10 of the Act on the provision of electronic services.You have the right to withdraw your consent to the processing of your personal data at any time. Withdrawal of consent will not affect the lawfulness of the processing which was carried out on the basis of your consent before its withdrawal.

Information Clause for natural persons (also one person companies) and also for persons authorized for contact:I declare that I have read the information clause and consent to the processing of personal data provided in this document for realising the certification process in agreement with Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation).

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