File no.: .
Address: City:
The manufacturer requests a conformity assessment of the equipment according to the module (or combination
of modules):
The manufacturer declares that a similar request for EU-design or type-examination, according to modules
B, G or H1, has not been lodged with any other notified body.
Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
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To be filled in by LR-Nederland
File no.: .
Name: Address:
City: Country:
Name: Address:
City: Country:
Description / type:
Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
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To be filled in by LR-Nederland
File no.: .
Capacity L
(vessel)
Heated surface m2
Fluid
(full name and/or composition)
Remarks
Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
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To be filled in by LR-Nederland
File no.: .
* In case of an application for an addition to an EU design or type approval, reference can be made to information
supplied with a previous application, as far as this is still valid.
(1) If not included, the application cannot be processed.
(2) Information for quotation purposes.
(3) Not necessary to send in with this application. Can be examined during the inspection phase.
(4) Design appraisal can be started, but not finalised without this information. EU-Certificate can only be issued after
this information has been made available.
(5) Required for planning visits.
(6) Information not mandatory to include in the application, but recommended in order to avoid complication
during the inspection phase.
(7) If not made available a note on the Certificate of EU-design examination will be placed, stating that this
certificate is only valid, after the missing information being approved by a notified body.
(8) When applying for an addition to a Declaration of EU-design examination, the original Declaration and possible
addition shall be included with the application.
Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
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To be filled in by LR-Nederland
File no.: .
Remarks
Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
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Appendix to:
Application Form Pressure Equipment
Pressure Equipment Directive PED 2014/68/EU
This appendix contains useful customer information for the inspection phase.
In particular it describes the documents needed to complete inspection requirements.
Please note that the documents mentioned will need to be available during (final) inspection.
A copy of said documents will have to be available for our surveyor.
List of materials * * *
* Possible, depending on the nature & extend of surveillance / monitoring. (Documents should be present,
copy can be requested at the surveyors discretion)
Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
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