SECTION 1 - YOUR COMPANY
Company Name
Contact Name
Address
Postcode
Telephone number
Mobile No:
Fax number
Email
Web site
SECTION 2 - THE EQUIPMENT TO BE TESTED
Model name/Number
Description of use
Hardware version
Software version
Type of testing required	-- pick one -- Full ComplianceFull Compliance Pre-CompliancePre-Compliance VerificationVerification InvestigationInvestigation ComparisonComparison
SECTION 3 - ABOUT THE TESTING REQUIRED
Do you want to attend the testing?	-- pick one -- YesYes NoNo Not sureNot sure
Is the test part of a development programme	-- pick one -- YesYes NoNo Not sureNot sure
Environment product is to be used in	-- pick one -- DomesticDomestic UnknownUnknown CommercialCommercial Light IndustrialLight Industrial Heavy IndustrialHeavy Industrial MedicalMedical RailRail Laboratory / Control equipmentLaboratory / Control equipment RadioRadio Automotive (Tier 1 or 2)Automotive (Tier 1 or 2) Automotive (PITO)Automotive (PITO) Automotive (EEC)Automotive (EEC) AerospaceAerospace SpaceSpace MilitaryMilitary Audio Audio OtherOther
Which countries / territories is the product to be sold into
Territory 1	-- pick one -- UKUK EuropeEurope USAUSA CanadaCanada AustraliaAustralia Japan WorldwideJapan Worldwide OtherOther
Territory 2	-- pick one -- UKUK EuropeEurope USAUSA CanadaCanada AustraliaAustralia Japan WorldwideJapan Worldwide OtherOther
Territory 4	-- pick one -- UKUK EuropeEurope USAUSA CanadaCanada AustraliaAustralia Japan WorldwideJapan Worldwide OtherOther
Territory 3	-- pick one -- UKUK EuropeEurope USAUSA CanadaCanada AustraliaAustralia Japan WorldwideJapan Worldwide OtherOther
Standards required
Commercial Emissions Standard 1	-- pick one -- EN55022 Class AEN55022 Class A EN55022 Class BEN55022 Class B EN55014-1EN55014-1 EN55011 Class AEN55011 Class A EN55011 Class BEN55011 Class B EN61326EN61326 EN55013EN55013 EN5501EN5501 EN6001-1-2EN6001-1-2 EN6100-3-2EN6100-3-2 EN6100-3-3EN6100-3-3 EN6100-6-3EN6100-6-3 EN6100-6-4EN6100-6-4 N/AN/A
Commercial Emissions Standard 2	-- pick one -- EN61000-3-2/3EN61000-3-2/3 EN55022 Class AEN55022 Class A EN55022 Class BEN55022 Class B EN55014-1EN55014-1 EN55011 Class AEN55011 Class A EN55011 Class BEN55011 Class B EN61326EN61326 EN55013EN55013 EN55015EN55015 EN60601-1-2EN60601-1-2 EN61000-3-2EN61000-3-2 EN61000-3-3EN61000-3-3 EN61000-6-3EN61000-6-3 EN61000-6-4EN61000-6-4 N/AN/A
Commercial Immunity Standard 1	-- pick one -- EN55024EN55024 EN55014-2EN55014-2 EN61326EN61326 EN50121-4EN50121-4 ETSI EN 301-489ETSI EN 301-489 EN60601-1-2EN60601-1-2 EN61000-6-1EN61000-6-1 EN61000-6-2EN61000-6-2 N/AN/A
Commercial Immunity Standard 2	-- pick one -- EN55024EN55024 EN55014-2EN55014-2 EN61326EN61326 EN50121-4EN50121-4 ETSI EN 301-489ETSI EN 301-489 EN60601-1-2EN60601-1-2 EN61000-6-1EN61000-6-1 EN61000-6-2EN61000-6-2 N/AN/A
Other EMC Standard	-- pick one -- Ford ABFord AB Ford ACFord AC Milstd 461EMilstd 461E GMGM DaimlerDaimler N/AN/A
Other EMC Standard	-- pick one -- Ford ABFord AB Ford ACFord AC Milstd 461EMilstd 461E GMGM DaimlerDaimler N/AN/A
Other
Notes
SECTION 4 - TECHNICAL INFORMATION REGARDING THE EQUIPMENT TO BE TESTED
Power supply
Is the equipment attended whilst in use?	-- pick one -- YesYes No No OccasionallyOccasionally UnknownUnknown
Is equipment switched on manually/automatically?	-- pick one -- ManualManual AutomaticAutomatic Automatic < twice a dayAutomatic < twice a day Automatic > twice a dayAutomatic > twice a day
What is the products primary power	-- pick one -- 240V AC direct240V AC direct 110V AC110V AC 240V/110V240V/110V 12V DC12V DC 24V DC24V DC 48V DC48V DC OtherOther 100V AC100V AC BatteryBattery
Current requirement	-- pick one -- Less than 75WLess than 75W Less than 13ALess than 13A Greater than 16AGreater than 16A OtherOther
Frequency of supply	-- pick one -- 50Hz50Hz 60Hz60Hz 50/60Hz50/60Hz 400Hz400Hz DCDC OtherOther
Single phase/3 phase	-- pick one -- Single PhaseSingle Phase 3 Phase 3 Phase DCDC
If DC supply, is it supplied with a plug top AC adapter	-- pick one -- YesYes NoNo N/AN/A
How long is the DC cable	-- pick one -- Less than 10M Less than 10M Greater than 10M Greater than 10M Less than 3MLess than 3M Between 3M and 10MBetween 3M and 10M N/AN/A
Input output cables
Does unit have any external cables (other than power)	-- pick one -- YesYes NoNo
How many are over 3m in length?	-- pick one -- N/AN/A NoneNone 11 22 33 44 55 66 77 88 99 1010 More than 10More than 10
Number of screened cables	-- pick one -- All screenedAll screened NoneNone 11 22 33 44 55 66 77 88 99 1010 More than 10More than 10
How many cables connect directly to outside cables?	-- pick one -- None None 11 22 33 44 55 66 77 88 99 1010 More than 10More than 10
Does the product have any external antenna connections	-- pick one -- None None 11 22 33 44 55 66 77 99 1010 More than 10More than 10
Physical properties of equipment
How long will it take to setup	-- pick one -- Less than 15 minutesLess than 15 minutes More than 15 minutes but less than an hourMore than 15 minutes but less than an hour Between 1 and 3 hours Between 1 and 3 hours More than 3 hoursMore than 3 hours
Product handling requirements	-- pick one -- PortablePortable Table top and portableTable top and portable Table top - not portableTable top - not portable Floor standing Floor standing Wall mountingWall mounting Rack mountingRack mounting Special arrangements requiredSpecial arrangements required
Size of the product	-- pick one -- Will go through a normal doorWill go through a normal door Largest dimension less than 1.5MLargest dimension less than 1.5M Special handling will be requiredSpecial handling will be required
Does the product require any special support (Water/Air)	-- pick one -- No No Compressed AirCompressed Air WaterWater Please contact mePlease contact me
Electrical properties of the product
Does it have clock oscillators above 9KHz	-- pick one -- YesYes No No Analogue electronics onlyAnalogue electronics only
If yes, please give frequency
Does the product contain magnetically sensitive components?	-- pick one -- NoNo YesYes UnknownUnknown
Does the unit contain a radio tx/rx device?	-- pick one -- NoNo YesYes UnknownUnknown
If Yes, please give frequency
Does the radio carry its own approval	-- pick one -- NoNo YesYes UnknownUnknown BluetoothBluetooth ISM frequencyISM frequency
Modes of operation
How many modes of operation will require testing	-- pick one -- Single modesSingle modes Two modesTwo modes Three modesThree modes More than three modesMore than three modes
Failure Criteria
Describe how we can monitor the equipment
SECTION 5 - PROVISIONS OF REPORTS
Report required
Summary test report (175.00)	-- pick one -- YesYes NoNo
Full test report (350.00)	-- pick one -- YesYes NoNo
Test Certificate (75.00 only with above report)	-- pick one -- YesYes NoNo
Paper copies of graphs on the day (FOC)	-- pick one -- YesYes NoNo
Electronic copies of graphs on the day (75.00)	-- pick one -- YesYes NoNo
Letters or email summary with graphs (75.00)	-- pick one -- YesYes NoNo
Please note that other than by appointment, reports are only released on payment of all invoices relating to that task
SECTION 6 - Additional Services
Do you require rectification/suppression consultancy	-- pick one -- YesYes NoNo
Do you require low voltage directive approval testing	-- pick one -- YesYes NoNo
Do you require competent body services	-- pick one -- YesYes NoNo
YOUR DETAILS
Your name
Your position
Date

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3C Test Limited
Silverstone Technology Park
Silverstone Circuit
Northants
NN12 8GX
Tel: +44(0)1327 857500
Fax: +44(0)1327 857747
Email: sales@3ctest.co.uk

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