★Declaration声明：The submitted samples with送测的样品具有: Fatalness危险性    Corrosion腐蚀性        Toxicity毒性

Flammability易燃易爆        Radioactivity放射性         Others其他请注明：     

★Product Name(产品名称):      ; Model No.(型号):       If too many models, Pls use the sample list into page2

★Applicant (申请公司中/英文)：     

★Address(申请公司中/英文地址) ：     

★Contact Person(联系人) ：      E-mail（电子邮箱）：     

★Tel (电话) ：         Fax(传真)：       Post Code（邮政编码）：     

If need to present in report, please select若报告需体现，请选择◎  More than one item, please note the No. :      Please provide company information请提供相应的公司信息：     

原产国  Country of Origin：     

目的国  Country of Destination：     

If you need other items in report, please specify 如果您的报告还需要注明其他项目，请说明：     

★Information above will be reflected in report, please fill in carefully. You have to pay RMB 100 yuan/report for the change fee if you need to change after issued.以上信息将体现在报告中，请仔细填写，报告签发后如需更改，收取更改费RMB 100元/份

★Service Required服务要求：Another requirement beside following options, please remark以下选项之外的另外需求，请说明     

 ◎    个工作日完成;   Special Service 特殊服务要求  个工作日完成， Surcharge加收     %fee 费用

★

Report Service

报告

服务

Please select请选择  ◎    If you require both English and Chinese reports will need to charge more RMB 200 yuan/report 如出中英文两种报告需另加收RMB200/份

Please select请选择  ◎  

 Other, please specify其他请注明：     

Print report打印纸档正式报告（节约地球资源，请使用电子档正式报告-与纸档完全相同）

★Report Delivered To报告寄往◎ Please select请选择 ◎

If different from applicant, please provide address & contact information若不同于申请公司，请提供地址及联系信息:     

★Sample Kept

样品保存

◎ ★Express to pay快递到付支付方 ◎ If different from applicant, please provide address & contact information若不同于申请公司，请提供地址及联系信息:     

Test Request 测试项目申请：(请在□内打“×”Pls Choose the □)

RoHS Test RoHS测试:  ◎   Others其他（please specify请注明）：     

REACH SVHC Test 欧洲REACH高度关注物质测试:

◎  If you need to do more batches, please specify如需要做多批次，请在此注明：     

Packaging Materials Test包装材料测试: 94/62/EC US TPCH (CONEG)   Others其他（please specify请注明）：     

Battery Test电池测试:  2006/66/EC   U.S. Public Law 104-142   Others其他（please specify请注明）：     

Total Lead Content总铅含量

CPSIA 16 CFR 1303 SOR/2010-273 SOR/2005-109 

Entry 63 of Annex XVII in REACH

Total Cadmium Content 总镉含量 Entry 23 of Annex XVII in REACH (91/338/EEC)

Soluble Heavy Metal Content可溶性重金属含量:

EN71-3 ASTM F963 ISO8124-3 SOR/2011-17

Hexavalent Chromium Content 六价铬含量

PAHs 多环芳香烃 GS 18种  Entry 50 of Annex XVII in REACH 8种

Phthalate 邻苯二甲酸酯

CPSIA Australia DEHP Entries 51&52 of Annex XVII in REACH (2005/84/EC)

CA65 “3P standard” CA65 6P AB1108  ST2012  SOR/2010-298

VOC 挥发性有机化合物

GB18581 GB18582 GB24613 GB24410 GB24408 HJ2537

GB15979 YC/T207 EN71-9

Others其他：     

Nickel Release 镍释放量, Entry 27 of Annex XVII in REACH

Dimethyl Fumarate (DMF)富马酸二甲酯, Entry 61 of Annex XVII in REACH(2009/251/EC)

Halogen (F, Cl, Br, I) Content 卤素含量

Formaldehyde 甲醛  Disperse dyes 扩散性染料

Azo dyes 偶氮染料, Entry 43 of Annex XVII in REACH (2002/61/EC)

NP&NPEO 壬基酚和壬基酚乙氧基醚,Entry 46 of Annex XVII in REACH

OP&OPEO辛基酚和辛基酚乙氧基醚

Organostannic Compounds有机锡化合物 Entry 20 of Annex XVII in REACH (TBT, TPT, DBT&DOT)

Phenols 苯酚类物质   PCP五氯苯酚    TeCP 四氯苯酚

                      TriCP 三氯苯酚  o-PP 邻苯基苯酚

PFOS全氟辛烷磺酸盐,Regulation (EC) No 850/2004 Annex 1  PFOA Others其他：     

★If liquid/ink sample若为液态/油墨类样品：Dry testing 烘干测试  Direct testing直接测试   KORIN disposal KORIN自行决定

Invoice & Payment (If the payer is different from the applicant, please provide below information)

发票和付款（如果付款人不同于申请商，请提供如下信息）：Payer’s Name 付款人名称：     Address 地址：     

★Authorized Signature申请人签名(盖章）：               Date日期：     

Remark备注：