Manufacturer’s or the authorized representative’s name:
Address:
Contact person(s):
Type of Product(s):
Vessels Assemblies	Pressure accessories Safety accessories	Piping Boilers Others:
Conformity assessment module(s):
Module D Module D1	Module E Module E1	Module H Module H1
Product Standard(s) applied:
Quality system information:
EN ISO 9001 Expiry date:	EN ISO 3834 Expiry date:	Other: Expiry date:
Status:	Certified	In process	Not yet applied
Certified by:
Human resources:
Total # employees:	# in engineering:	# in production:
Technical resources:
Foundry Machining Cold forming Hot forming	Welding Brazing In-house NDT In-house laboratory
Shared functions if part of corporate group: (e.g material sourcing)
Production related outsourced processes:
For the authorized representatives only Copy of manufacturers mandate enclosed

The undersigned hereby declares that the same application has not been lodged with any other
notified body than Kiwa Sweden AB 0409

Kiwa Sweden AB may subcontract specific activities

Kiwa Sweden AB may not subcontract any activities

Applicant/Manufacturer confirms that he/she has been informed about Kiwa Sweden terms and
conditions” for granting, maintaining, extending, suspending and withdrawing certification as seen by
the document “General and special sales and delivery conditions”
(https://www.kiwa.com/se/sv/om-kiwa/allmanna-leveransvillkor/)
For manufacturers or authorized representatives who apply with Kiwa Norge, the commercial conditions at (https://www.kiwa.com/no/no/salgsbetingelser/) will apply together with Special Conditions of Sales and Delivery of Kiwa Sweden.

Signature:
Name:
Place:	Date:	Click here to enter a date.

Product information: Manufacturing site(s), if other than page one:

Project: User of equipment, name and address:

Equipment Number:	Equipment type 1	Equipment type 2	Equipment type 3
Type of product:
Name/Type designation:
Category:
Fluid/Service
No. of Models if series Min. and max. size
Design pressure
Design temp.
Nominal dia./Volume
Length
Material Standards
External loads: Nozzles (nr. of) Earthquake Wind, snow, ice Other:
Other essential design parameters:
Enclosures: Drawing/ sketch Data sheet Other:
Has any deviation from quantitative requirements given in PED Annex I Section 7 been made? Yes No (Ref WGP Guideline H-06)
Certificate should be issued in Swedish English
Contact person(s): (e-mail, phone, address )

Page 3 of application is informative and may be omitted.