N° d’ordre :

APPLICANT

Name：
Full address/Postcode：
Contact：
Tel/Fax：
Email:

MANUFACTURER

Name：
Full address/Postcode：
Tel/Fax：

PRODUCT INFORMATION

Provide a short description of the product :
Electrical parameters：
Ex mark：
Requested Category:
Cat. 1(zone 0)　　Cat. 2(zone 1)　Cat. 3(zone 2)
Requested Classification：
　□gas　□dust　□gas-dust

the product is not certified, please provide us with the information as listed below :

• □　Cross sectional drawing(s)
• □　Dimensions (outline drawing) , weight
• □　Range of working ambient temperatures
• □　Electrical data and diagrams for IS
• □　list of already certified components
• □　Electrical parameters (u, i, p…)

tick if supplied

protection (type)

Questions

《 d 》

Plastic enclosure or part of plastic nclosure ?

Non metallic part as flame path ?

Sintered material ?

Is there potential risk due to non electrical parts ?

Free internal volume ? dm3

《 e 》

Plastic enclosure or part of plastic enclosure

IP54 confirmed by a notify body report ?

IP degree requested ?

Glass part ?

《 p 》

Free internal volume ?　dm3

Internal emission of explosive gas ?

Certified over pressure module ?

Presence of [ia] elements ?　Number :

Glass part ?

《 m 》

Equipment potted in a metallic enclosure ?

Equipment potted in a plastic enclosure ?

Equipment potted without enclosure ?

《 ia 》

Type of equipment :

Zener barrier?

Sensor, probe, contact ?

PCB ? 
　　　　　　　　　　Surface< 100 cm²
　　　　　　　　　　Surface> 100 cm²

variation

Technical product modification ?
Provide detailed modification description)
Additioaln Model(s) ? 　Number :
Simple modification without test (e.g. : change of address) ?