Simtars

Training, Testing and Certification Centre

2 Robert Smith Street, Redbank QLD 4301, Australia Phone +61 07 3810 6381
Postal Address: PO Box 467, Goodna QLD, 4300 Australia

Application for Testing of Equipment

1. Applicant:
Company Name:
ABN (if applicable)
Address (Street):

Postal Address:

Contact Name:
Phone: Mobile:
Facsimile: E-mail:

2. Description of Equipment (attach page if required):

3. Test Specification: (e.g. Standard, exclusions, test criteria)

4. Documentation:
Tick as applicable -
Drawings enclosed

Manuals/additional documentation

5. Additional Information:

6. Address for Return of Equipment:

Courier& Account Number:

7. Form of Undertaking

I, the authorised representative of ,

hereby request Simtars to examine and test the equipment described herein. It is understood and accepted that
no action or suit for damages shall lie against the Resources Safety and Health Queensland, the Minister or any
officer of Simtars, in respect of any damage to apparatus, component or equipment resulting from testing
associated with this application.

I also accept Simtars - Standard Terms and Conditions of Contract. (AF0002)

Signature: Title/Position Date:

EF0026 Status Date: DRAFT Page 1 of 1