Hazardous Substances of Textile and Footwear Test Request Form Name of Applicant (or Report Title): Address: GUI # (Taiwan Only): Person to Contact: Tel: Ext.: Invoice to: same as above 全國公證填寫 Job No.進件編號： E-mail: Fax: 收件確認(樣品狀態符合測試要求) 是否審查(由 Intertek 客服人員簽章): Address: GUI # (Taiwan Only): Person to Contact: E-mail: Tel: Ext.: Fax: The applicant agrees and promises to be the payer, if the relevant invoices are unable to be settled by the appointed payer. Item/Style No. Sample Description Country of origin: Good exported to: Buyer: Manufacturer: Agent: Material composition and finishing: Other Information to be stated on test report: ** One TRF for one test report, please provide separated TRF when individual report is needed. Return Sample: No Yes (1. By client within one month after report issued or sample will be destroyed automatically; (Default: No if unselected) 2. By Intertek with client paid courier fee) General Test (If any specified method please fill it in) CPSIA (HR 4040) pH- Value – method: Use and abuse test (To determine “accessibility”) Formaldhyde – method: Lead in coating: CPSC SOP (default) # HD-XRF Extractable Metals - 10 elements Lead in substrate: CPSC SOP (default) # HD-XRF # Chromium VI in leather – method: Accept HD-XRF when insufficient sample: Yes No with aging condition (80 deg C, 24hr, 20%RH) Small part (incl. Abuse test) – for 3 years and below Total lead – method: Sharp point / edge (incl. Abuse test) – for 8 years & below Total cadmium – method: Phthalates (DEHP/DBP/BBP/DINP/DIDP/DNOP) Pesticides 60 items – method: Flame retardants (please check below) – method: PCP TeCP TriCP – method: PBBs TRIS TEPA PentaBDE OctaBDE DecaBDE HBCDD SCCP TCEP Phthalates (please check below) – method: Solvent residues NMP DEHP DBP BBP DINP DIDP DNOP DIBP DIHP DHNUP DnHP DMEP DPP Solvent residues DMAC DiPP PiPP Dimethyl formamide (DMFa) Organotin (please check below) – method: Dimethyl fumarate (DMFu) TBT TPhT DBT DOT MBT NP OP – method : oPP – method: NPEO OPEO – method: PFCs (please check below) – method: Nickel release for metal (coated) - EN 12472/1811 PFOS PFOA PFUdA PFDoA PFTrDA Nickel release for metal (uncoated or Ni-plated) - EN 1811 PFTeDA Nickel Spot Test (Qualitative) - CR 12471 Azo dyes 22 items 24 items – method: Short chained chlorinated paraffin (C10-C13), SCCP Allergenous disperse dye – method: Middle chained chlorinated paraffin (C14-C17), MCCP Carcinogenious dye – method: PAHs (please check below) – method: Chlorinated Benzenes and Toluenes – method: 8 items (Reach Annex 17) 18 items (ZEK) 24 items e-mail Fax Hard copy (extra postage) Delivery: with sample photo with sample card Report: Please provide print type if submitted fabric contains printing: Dye print Pigment print Shuttle 1-1.5 Express 3-4 Regular 5-7 working days (+100% Surcharge) ** working Days (+50% Surcharge) ** working Days The promised service of working days is only oral results not including the time of typing, pick- up & delivery or mailing. **Shuttle and Express is not applicable for all tests. 本申請廠商茲申請上述之試驗並同意所有試驗依本申請書前頁與背面所訂之試驗條款履行。其價款依照本申請廠商已過目之最新收費標準。 We request for the above tests and agree that all testing will be carried out subject to INTERTEK TESTING SERVICES TAIWAN LTD's scale of charges as set forth in their latest price list of which we have seen a copy and upon and subject to the terms and conditions set out hereon and overleaf. 負責人簽名或公司印章:(Authorized signature or company chop) 日期(Date): Intertek Testing Services Taiwan Ltd. 1F, No. 419, Ruiguang Rd., Neihu District, Taipei City 11492, Taiwan Tel: (+886-2) 6602-2888 Fax: (+886-2) 6602-2410 Web: www.intertek-twn.com Professional • Innovative • Reliable FC04-CS009e Rev 4.6 Page 1 of 2 Intertek Testing Services Taiwan Ltd. 1F, No. 419, Ruiguang Rd., Neihu District, Taipei City 11492, Taiwan FC04-CS009e Rev 4.6 Page 2 of 2