ePCS/FOR/01-3

DECLARATION OF APPROVAL FROM RELEVANT AUTHORITY

Declaration of Approval from Relevant Authority (To be filled by Applicant)

Company :

Product :

In connection with my/our activities of manufacturing/trading the product which will be

granted the Certification Mark/Product Listing Mark, I/we declare that:

Has obtained approval from the relevant local authority (PBT) and/or
other Regulatory Body (e.g. ST, MIDA, BOMBA and etc.) to
manufacture/sell the above product;
(Evidence of approval is attached)
or

Is seeking approval from them.

(Evidence of application for approval is attached)

I/we undertake responsibility to revoke this application should there be a rejection by the
respective authority or registrar. I/we also undertake not to involve SIRIM QAS
International Sdn. Bhd., in any legal proceeding pertaining to the above mention
approval.

An authorized Signature Applicant’s stamp:

representative
of the applicant
shall put his
signature in this
Name
section.
Designation
Date
Address

SIRIM QAS International Sdn. Bhd Product Certification Page 1/1

Issue: 1 Rev: 1