Name

Address

Application number

Tests by this laboratory

Date/period of tests

Name(s) of test engineer(s)

Accredited by

Number:

Expires (date):

Accreditation includes R 60

☐ Yes

Edition: ☐

☐ No

Details of relevant peer assessment or assessment by other means

In case tests have been performed at locations other than the address of this laboratory, give details here

Name of the responsible person

Date of signature

Stamp (if applicable) and signature of the responsible person

Remarks: ‌

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