Laboratorio Oficial J.M.

Madariaga (LOM)
Application form for IECEx Quality Assessment Report (QAR)

Applicant:
Address:
Contact person:
Phone:
Fax:
E-mail:

Manufacturer (if different from applicant):

Address:
Contact person:
Phone:
Fax:
E-mail:
Invoice issued to:
Invoice address:
Phone:
Fax:
E-mail:
NIF o CIF (Spain) (attach a copy):
intra-Community trade number (UE) (attach a copy):
TAX Register number (other countries) (attach a copy):

Facility location:

Language of audit:

Requests submitted to LOM:

Evaluation for obtaining the IECEx Quality Assessment Report according to ISO/EC 80079-34:2012.
Extension of the scope of the Quality IECEx Assessment Report no.:____________.
Reassessment
Surveillance
Others

Scope (products)

The undersigned:
- Agrees on IECEx Certification Body method and system of payment and to facilitate the necessary
information for the evaluation of the Quality System.
Comments:

Date and signature:

RCPIECEX 01.1 Page 1 of 2 2014-12-09

 Laboratorio Oficial J.M. Madariaga (LOM)
Application form for Quality Assessment Report (QAR)

Attached documents:
- Organization chart of the company.

Total number of Employees __________

Number of Ex persons on site _________

- Subcontracted processes that affect the conformity with the requirements.

- Quality manual.
- Listing of quality system procedures.
- A copy of the quality plan for the Ex equipment or equipment categories included in the scope.
- Certificate ISO 9001 (if one exists) and its external audit report (if one exists).
- Test reports (ExTRs).

Consulting services: (In order to maintain the objectivity and impartiality in the conformity evaluation activity, it
is requested to inform LOM if the company has resorted to consulting services concerning management
systems)

Comments:

Date and Signature:

Note: By signing this application the manufacturer/applicant declares:

- That they know the IECEx certification procedures, and their rights and obligations as a manufacturer, including ensuring that any
promotional material does not contain misleading information that may infer products not covered by IECEx certification.

- That they know and meet the certification criteria required and have the experience to carry out the related activities.

- That the same application has not been sent to any other ExCB.

- To abide by the rules of the IECEx scheme and ExCB’s certification conditions.

RCPIECEX 01.1 Page 2 of 2 2014-12-09