Amazon Direct Validation Program Test Request

Submitter Information (Please fill in information and check appropriate boxes) 申请人信息（请填写资料并勾选相应的方框）

Submitter Company Name 申请人公司名称:

Address地址:

Contact Person联系人:

Tel电话:

Email 电邮:

Invoice to Submitter申请公司付款:

Yes 是

No, please specify the below information 如付款人与申请公司不同,请提供详细资料

Company Name 申请人公司名称:

Address地址:

Contact Person联系人:

Tel电话:

Email 电邮:

SELLER INFORMATION (If different from the above, please provide Amazon registration name) 卖家信息（如与上述不同，请提供亚马逊系统注册名称）

Seller Company Name 卖家公司名称:

REPORT recipient (If different from the above, please provide) 报告接收人（如果与上述不同，请提供）

Report Recipient 报告接收人:

Email 电邮:

MANUFACTURER INFORMATION制造商信息

Manufacturer Name 制造商名称:

Address地址:

Sample Information (Please fill in information and check appropriate boxes) ^Mandatory field

样品资料（请填写资料并勾选相应的方框）请留意 ^ 是必填信息

^ Amazon Test Request ID:

TIC Reference TIC参考号:

^ Product Description 样品描述:

^ ASIN 亚马逊识别号:

Style # / Model # 型号:

Country of Origin 原产国:

No. of Sample Submitted 样品数量:

Labeled Age Grade (if applicable) 标示年龄级别（如适用）:

Retest重新测试.:

No否

Yes, please state previous report no 是，请注明先前的报告编号 :

Return Samples退还样品.:

No否

Yes, (shipping and handling charges apply) 是，（需支付运输和处理费用）

Quotation before testing 测试前报价:

No否

Yes是

Product Test Request (Please include test methods and standard) 产品测试请求（请包括测试方法和标准）

Request test (which is not listed in quotation, please indicate test method if possible or special request)

请求测试（如果报价中未列出的测试，请尽可能注明测试方法或特殊要求）

Actual Testing 实试

Document Review 文档审查: Report # 报告号

^Destination country 目的地:

Others 其他:

SERVICE REQUIRED 服务要求: (Check One) 请选择

* Limited tests available. Please call for details有限的测试可用。请致电了解详情。

General (except Toy & Juvenile Products) (玩具及青少年产品除外的产品)

Regular 常规

*Express 40% Surcharge 加急

*Emergency 100% Surcharge 特急

General (America, please inquire with lab location for the surcharge)

Regular

*Express

*Emergency

Toy & Juvenile Products (Asia) 玩具及青少年产品 (亚洲)

Regular常规

*Next Day 150% Surcharge 一天加急

*Next 2 Days 100% Surcharge两天加急

*Next 4 Days 40% Surcharge 五天加急

All services of Bureau Veritas Consumer Products Services Division are strictly offered, and can only be accepted, under the CPS Conditions of Service. Any party that requests said services, confirms said services, or makes any payment for said services does so agreeing automatically that: (a) it irrevocably accepts and agrees to the CPS Conditions of Service; (b) it waives all rights to change or challenge the CPS Conditions of Service; and (c) the CPS Conditions of Service are final and, unless expressly agreed otherwise by Bureau Veritas, any additional conditions sought to be imposed on any service or payment shall be invalid. The CPS Conditions of Service can be accessed through this link:

http://www.bureauveritas.com/home/about-us/our-business/cps/about-us/terms-conditions/

Date:

Authorized Signature: