CUSTOMER REQUEST FORM

Doc Id: F-GOP-002-002 Issue 01 Rev 12

1. Please fill correctly to enable us understand your requirements and issue a formal offer.
2. No information shall be disclosed to any third party without the written consent of the customer in conformity with ITC Policy &
procedures.
3. Customer is requested to provide the Instruction Manual /Gerber of the sample / Device Under Testing (DUT)
a. Incase, no Instruction Manual present, detailed instruction on how to operate the DUT / Sample can be provided by the
Customer (in printed or hand written form).
b. Customer may be asked to visit the Lab to demonstrate the working of the DUT / Sample.
4. ITC take no responsibility for damages to the supplied sample during testing, storage or transportation.
5. Customer has to make arrangement for taking back of the sample within 3 weeks after the issue of the test report. After this period
ITC INDIA PVT. LTD. reserves the right to dispose off the samples as it deems fit.
6. Customers understands fully that ITC will have the right to disclose all information to a government agency when required by law, In
such case ITC will notify the customer prior to release the confidential information.
7. Information about the Customer obtained from sources other than the customer shall be confidential to the laboratory and shall not
be shared with the customer.
8. Unless inherent in the requested standard, if the Decision Rule is to be given by the Customer it shall be specified against the
Specified Standard* according to which testing is to be done.
9. If Decision Rule is to be given by the Lab, Decision Rule ILAC G8: 2009 rule will be followed, where guard value (W=1u) will be made
(TL=AL+W).
COMPANY INFORMATION:
ITC Quotation Reference:
Company Name VULCAN SOCIAL ENTERPRISE COMPANY LIMITED
GST No. 0315155575
Name PHAN THI KIM NGAN Position Operations Manager
Name / Designation of Mobile Tel. +84931888523
Requester Email ngan@wearevulcan.com Website wearevulcan.com
197 Nguyen Hoang, An Phu Ward, Thu Duc City, Ho Chi Minh city, Vietnam
Main Operative Office
SAMPLE / WORK DETAILS:
Sample Details
S. Product Name / Model Specify Standard* Decision Wattage Voltage Operating Frequency
No. No. according to which Rule ( ×/ ) (AC/DC) Current
Testing is to be done: (AC/DC)
EN 60601-1:2006 +
A1:2013 +AC:2014 +
Vulcan Multi-grip
A12:2014 + A2:2020:
Myoelectric Hand
Medical electrical
1 (includes Hand, BLE 8.4 W 8.4V (DC) 1A (DC) 2.4 GHZ
equipment - Part 1:
Adaptor, Battery and
General requirements
MyoBand)
for basic safety and
essential performance
1.1 HAND 8.4 W 8.4V (DC) 1A (DC) 2.4 GHZ
1.2 BLE adapter 0.84 W 8.4V (DC) 0.1A (DC) 2.4 GHZ
1.3 Battery 16.8 W 8.4V (DC) 2A (DC) NO
1.4 Myoband 0.84 W 4.2V (DC) 0.2A (DC) 2.4 GHZ

ADDITIONAL INSTRUCTIONS
Test Report Required X Full Specific
Statement of Conformity required or not X Yes No

For BIS: CRS Scheme / Product Registration

*Also Submit Instruction for Use / Operating Manual along with the sample.
Note: Photograph & Videos of the device under testing are property of ITC and can be used anonymously by the lab for promotion purpose.
I hereby agree to declare the same.

Date of Request: __________________________________ Sign & Stamp:_____________________________________

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Laboratory Use Only:
Review performed for ( ×/ )
Quotation is referred or not :
 CUSTOMER REQUEST FORM
Doc Id: F-GOP-002-002 Issue 01 Rev 12
- Specified Standard is latest or not :
- Do we have the technical capability to do this test
- Is the test method suggested by customer complete or not
- Any comments to be clarified to the customer by mail.
- Sample ID
Verified By: Date: