TRF Mold Screening Test - #3637 Samples of PO#6852

Bureau Veritas Consumer Products Services Vietnam Ltd.
TEST REQUEST FORM

Lot C7-C9, Conurbation 2, Cat Lai Industrial Zone, District 2, HCMC, VN
Tel: 84-8-37421604~6 - Fax: 84-8-37421603 - Email: submission_info@vn.bureauveritas.com
A. SERVICE REQUIRED
Regular (5-7 Working Days or per testing nature) Rush (2-3 Working Days - 40% Surcharge) Priority (Next working day - 100% Surcharge)
First Time Test Re-Test (if retest, please write previous report# at beside section) Previous Report#
CPC/GCC (Children Product Certificate/ General Conformity Certificate) request ($25/each CPC/GCC). Please also fill in Additional form (page 2) for Importer and Person Maintaining Records
Quotation before testing (test will be placed on hold until receiving confirmation) or testing per provided Quotation#
B. APPLICANT (VENDOR/SUBMITTER) INFORMATION: (We will use company name/address/ contact person info of this section to show on report)
Company Name: Dimensions Furniture, Inc
Address & Post Code: 341 Gradle Drive, Carmel, IN 46032, USA
Contact Person: Jenny Hoang Tax Code :
Tel: 1-317-218-0025 Fax: 1-317-218-0028 Email : jenny@dimensionsfurniture.com
CC Reports To Email :
To DIMENIONS recipient list :

mstriebel@dimensionsfurniture.com
jstriebel@dimensionsfurniture.com
rmcnew@dimensionsfurniture.com
jboyd@dimensionsfurniture.com
rpfrommer@dimensionsfurniture.com
rdrake@dimensionsfurniture.com
cproctor@dimensionsfurniture.com
steven@dimensionsfurniture.com
daniel@dimensionsfurniture.com
eric@dimensionsfurniture.com
Bruce@dimensionsfurniture.com
alvin@dimensionsfurniture.com
jenny@dimensionsfurniture.com
rcrabtree@dimensionsfurniture.com
cle@dimensionsfurniture.com
Invoice to Applicant: Yes No (If no, please fill in billing information below) Report to Applicant: Yes No (If no, please fill in “Report To” below)
Billing Company: Report To (Company name):
Address: Address:
Contact Person: Contact Person:
Tel/Fax: Tax Code : Tel/Fax:
E-mail : dheckaman@dimensionsfurniture.com
cproctor@dimensionsfurniture.com
E-mail:
jenny@dimensionsfurniture.com
steven@dimensionsfurniture.com
alvin@dimensionsfurniture.com
C. PRODUCT INFORMATION: (if any information is not available or not needed to show on test report, please leave blank)
Sample Description / Product Name #3637 samples of PO#6852

Phase/Stage of Production Development Production Others Date of Production
Manufacturer Tien Phu Buyer/Client Cinmar (GrandinRoad Brand)
Country of Origin Vietnam Agent
Type of testing Country of Destination/Market USA
Item# P.O. # 6852
SKN/SKU# Color
UPC# Wood Type or specie/ Material:
Final packaging Yes No, final packaging is not available Quantity of sample(s) submitted: 3 pcs
Assembly Instruction included Yes No Fiber content (for fabric/PU/vinyl)
State Age Grade Used for testing OR Age Grade determined by BVCPS Vietnam
D. TEST REQUEST: ( If no desired test request found, please specify at section E)
PRODUCT (QUALITY) TEST: TRANSIT (PACKAGING) TEST:
Per protocol/standard: Per protocol:
Additional Product (Quality) test: please choose below: Per test method: please choose below:
US Lead in surface coating ( CPSIA – 16 CFR 1303 – Limit: 90 ppm ) ISTA 1A ( for item ≤ 150Lbs)
US Lead in substrate ( CPSIA – Limit: 100 ppm ) ISTA 1B ( for item > 150Lbs)
Canada Total lead content in surface coating (CCPSA / Surface coating materials regulations) ISTA 1C/1D (All types of weight)
Illinois lead content in surface coating (40ppm)
Illinois lead content in substrate (40ppm )
Phthalates content, please state name (Ex: BBP/ DBP…):
ISTA 2A ( for item ≤ 150Lbs)
ISTA 2B ( for item > 150Lbs)
Heavy metals in coating - ASTM F963 (US)
ISTA 2C ( for Case Goods) Atmospheric Conditioning (Optional)
Heavy metals in substrate - ASTM F963 (US)
ISTA 3A ( for item ≤ 150Lbs) Atmospheric Conditioning (Optional)
Canada Heavy metals content in surface coating (CCPSA / Toys regulations)
NMFTA, Item 181
EN 71-3: 2013 (19 heavy metals)
Fedex (ISTA 6 (All types of weight)
CA TB 117-2013, please fill out which section: Section 3- Resilient material
Bursting strength - TAPPI T810
Edgewise Compressive Strength - TAPPI T839
CPSIA testing to complete reasonable testing program for Third Party testing:
CPSIA Total Lead content in Surface Coating – 16 CFR 1303 (Limit: 90 ppm) (included use & abuse test with additional charge $26/item for children product)
Individual or Composite (up to 3 colors/ coatings) (more sample size is needed) (Required Individual result if fail Yes or No)
CPSD-HL-TRFS-VN-TRF-V27 Page 1 of 4 Apr. 25, 2017
TEST REQUEST FORM
CPSIA Total Lead content in Substrate (included use & abuse test with additional charge for children product) – Limit: 100 ppm
Individual or Composite (more sample size is needed)
CPSIA Phthalates content (Individual only) - BBP/DBP/DEHP content – DNOP/DINP/ DIDP content Client’s DnHP content Other, please state name:
EU MARKET (Please write clearly test standard/method with version , ex: BS EN 12520:2015)
Indoor furniture:
Please select level for testing: Level 1 Level 2 Level 3 Level 4 Level 5
Outdoor furniture:
Please select level for testing: Camping Level Domestic Level Contract Level
Children furniture:
Please do the mold Screening test for the 3 samples.
- We already marked some areas on the samples that we have treated,

please choose other random suspected areas on the wood and
upholstery to reach 10 suspected areas to do the test to get 1 final test
result for each sample.
- Please make sure the report shows separate results for each sample(3
results)
*** Sample will be returned after test

__________________________________________________________________________________________________________________________
(All requested test(s) will be performed according to the test method(s)/ standards(s) appropriate to industrial practice which is determined by the laboratory, unless specified.)
Date: _____________________________ Authorized Signature and Chop: _____________________________________________________________
ADDITIONAL INFORMATION FORM FOR CPC/ GCC

CPSIA applicable rules review and CPC/GCC under BVCPS CPC/GCC service scope- Request Form
Note: Only fill out below sections if GCC/CPC checkbox in page 1 is selected.

TEST REQUEST FORM
MANUFACTURER’S INFORMATION
(Required for Domestic Manufacturer’s)
Company Name:
Mailing Address:
Telephone No.:
IMPORTER’S INFORMATION
(Required for Imports)
Company Name:
Mailing Address:
Telephone No.:
PERSON MAINTAINING TEST RECORD INFORMATION
Contact Person:
Mailing Address:
Telephone No.:
Email Address
Date of Manufacturer:
(MM/YYYY)
Place of Manufacturer:
(City / Province / Country)

TEST REQUEST FORM

TRF Mold Screening Test - #3637 Samples of PO#6852

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Bureau Veritas Consumer Products Services Vietnam Ltd.

TEST REQUEST FORM

To DIMENIONS recipient list :

Sample Description / Product Name #3637 samples of PO#6852

Please do the mold Screening test for the 3 samples.

- We already marked some areas on the samples that we have treated,

*** Sample will be returned after test

Date: _ Authorized Signature and Chop: _________________________________

ADDITIONAL INFORMATION FORM FOR CPC/ GCC

CPSD-HL-TRFS-VN-TRF-V27 Page 2 of 4 Apr. 25, 2017

PERSON MAINTAINING TEST RECORD INFORMATION

CPSD-HL-TRFS-VN-TRF-V27 Page 3 of 4 Apr. 25, 2017

CPSD-HL-TRFS-VN-TRF-V27 Page 4 of 4 Apr. 25, 2017

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