Information Gathering Form

Note: if possible please provide all this information in electronic format (PDF or MS Word)

Section 1:	General Information

Please indicate if this application is:

Production: Please indicate if this product is a limited production item (one of, or single batch of products) or if it is your intention to manufacture the product on an on-going basis.

Applicant’s Information:

Company Name (Full Legal Name):
Contact Name (Name, Title, department)
Address: (Number, Street, City, Prov/State, Postal/Zip Code, Country)
Phone Number	Fax Number
Email Address	Website Address:

Billing: (if different from above)

Company Name (Full Legal Name):
Contact Name (Name, Title, department)
Address: (Number, Street, City, Prov/State, Postal/Zip Code, Country)
Phone Number	Fax Number
Email Address	Website Address:

Location of Evaluation

(If the evaluation is to take place at a location other than the applicant’s address above, please indicate this below):

Company Name (Full Legal Name):
Contact Name (Name, Title, department)
Address: (Number, Street, City, Prov/State, Postal/Zip Code, Country)
Phone Number	Fax Number
Email Address	Website Address:

Section 2: Product Information (Please attach picture)

Brief Description of Product:

Type of Equipment: (Brief description, include intended use)
Model :
Serial Number(s)
Electrical Rating	Voltage	Current	Phases	Frequency
Overall Dimensions (m)	Width	Length:	Height:	Uncrated Weight (Kg)
Ambient Temperature
Selected Standard

Other Information for Haz-Loc equipment (Please attach schematics and drawings)

Haz-Loc rating:	Class Division Group(s) or Class Zone
Selected Standards:
Protection Method:	Other: ________________
Equipment Group
Gas Group	___________________
Temperature Class	T	(ex: T1 – 450°C; T2 – 300°C, T2B, 260°C ; T2C – 230°C, T2D – 215°C, T3 – 200°C T3A – 180°C; T3B – 165°C, T3C – 160°C ; T4 – 135°C, T4A -120°C, T5 – 100°C, T6 – 85°C)

Please provide the following information (in electronic format if possible):

Product Description/ Product Brochure, Photographs
Product Schematics/ Wiring/Block Diagrams/Constructional/Assembly Drawings
Mechanical Drawings
Bill of Materials (BOM List)
Component datasheets for all critical components and power circuit components (Electrical Motors, motor protections, disconnect means, transformers, fuse holders, fuses, gas sensors if (applicable) along with Certification Body (CSA, UL, LC) file numbers.
Installation/Operating/User Manuals
Copy of Hazardous Area Classification (HAC) drawings, clearly indicating all Zones & the ordinary location areas with all boundaries identified. Note: In Ontario, the drawings must be stamped by a PEng.
Electrical Nameplate Ratings (Volts, Hz, Amps etc.)
Haz-Loc Nameplate Ratings (where applicable)
Caution and other markings for the equipment (for ESAFE review)
List of Intrinsically safe barriers, Control Drawings and Intrinsically Safe System Information (if applicable)
Provide calculations when applicable for purging systems and/or ventilation requirements
Explanation of functionality of interlocks, emergency stop, resets, etc.
Any Test Data and Reports associated with the equipment (if available)
Copy of existing test reports issued by other certification body (if applicable)
Your target Completion Date

Section 3:

(The items in this section are required only for on-going manufacturing or if the product is being installed in other than Canadian locations.)

Intended Markets

(Please list countries where the product will be installed)

Manufacturing Location (required only for On-Going Manufacturing and if different from applicant above):

Company Name (Full Legal Name):
Contact Name (Name, Title, department)
Address: (Number, Street, City, Province/State, Postal/Zip Code, Country)
Phone Number	Fax Number
Email Address	Website Address:
ISO 9001 Certified	Other (please indicate):

Section 4

Please return this RFQ to the ESAFE Customer Service Centre at hazloc@esafe.org

Thank you for considering ESAFE and we look forward to working with you!