EU-MED Application Form

EU-MED Application Form

Application form for Conformity Assessments on Marine Equipment under Council Directive 2014/90/EU
1. Applicant
If application is made by the manufacturer from an address not within the EU then also details of the Authorized representative in the EU are to be provided under section 3 (Article 13 of 2014/90/EU)

Original equipment manufacturer / Authorized representative
Contact Person*

First NameLast Name
Email*
example@example.com
Company Name*
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number

Country CodeArea CodePhone Number
Website

Manufacturing Site
2. Manufacturing Site
Required if manufacturing site differs from the details in section 1.
Is the Manufacturing information different than the Applicant information?

YesNo
Contact Person

First NameLast Name
Relationship to the manufacturer
Email
example@example.com
Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Website

Authorized Representative within the Union: (Article 13 of 2014/90/EU)
3. Authorized representative within the Union: (Article 13 of 2014/90/EU)
(Application made by the manufacturer with address not within the EU, provide details of Authorized representative in the EU)
Company Name
Relationship to manufacturer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

Invoicing Details
4. Invoicing details:
Client Purchase Order No. - P.O. No.
Invoice Details - Use details as per section:

1. Applicant2. Manufacturing SiteOther as per below
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Conformity Assessment and Certification
Select type of conformity assessment and certification needed

EC Type Examination MED Module B certificationProduction – Quality assurance MED Module D certificationProduct – Quality assurance MED Module E certificationProduct Verification MED Module F certificationEC Unit Verification MED Module G certification
5. Type of conformity assessment and certification to be carried out by:
EC Type Examination MED Module B certification
Production – Quality assurance MED Module D certification
Product – Quality assurance MED Module E certification
Product Verification MED Module F certification
EC Unit Verification MED Module G certification

Marine Equipment Directive
6. Marine Equipment Directive
Description of Equipment & Model No's
Intended Conformity Assessment Procedure (Selected 1 or combination of 2 conformity modules)

BD/EFG
Serial Number(s) for MED Mod F or G
USCG Approval Number, if applicable.
According to the Mutual Recognition Agreement between EC and USA

Design and Performance Standards, Code and Rules
7. Design and Performance Standards, Code and Rules
MED Directive 2014/90/EU
Specify the implementation act
MED Item Number
Please enter the MED Item Number in the following format: MED/#.##@; Examples: MED/3.12d, MED/3.13, MED/1.2a, MED/1.1
Please indicate applicable MED Regulations & Testing Standards
Any other Standards

Document Checksheet for Initial, Renewal and Revision of Certification
11. Document Checksheet for Initial, Renewal and Revision of certification
Following information, as applicable, is to be submitted with the application form.
Checklist for MED Module B certification
MED Module B certification upload

Cancelof
Checklist for MED Module D/E certification
MED Module D/E certification upload

Cancelof
Checklist for MED Module F certification
MED Module F certification upload

Cancelof
Checklist for MED Module G certification
MED Module G certification upload

Cancelof

Applicant’s Representative
Name*

First NameLast Name
Position*
Email*
example@example.com
We hereby confirm that the same application has not been lodged simultaneously with any other Notified Body and that no Notified Body has previously refused certification for the product(s).
Signature*

Clear
Date*

DayMonthYear
Date
ABS Italy S.R.L. is a subsidiary of American Bureau of Shipping (ABS), the applicant is hereby informed that parts of the conformity assessment might be delegated to ABS or subsidiaries.
Copyright © 2021 American Bureau of Shipping
Our address is 1701 City Plaza Dr., Spring, Texas 77389, USA

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(You can also send your request to Customer Care at the street address above.)
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