Form 0920-0199 Standard Application Form initial

Standard Application Form
I

version 9. 20190409 _ 1

A.

Import XML

11

Form Approved: 0MB No.
0920-0109 Exp. Date: xx/xx/20xx
Export XML

Company Information

(A.1) Company Name
(A.2) Address Line 1
(A.3) Address Line 2
(A.4) City

B.

(A.5) State

(A.6) Country

(A.7) Postal Code

(B.5) Country

(B.6) Postal Code

1 lusA

Plant Address

D Same as Company
(B.1) Address Line 1
(B.2) Address Line 2
(B.3) City

C.

(B.4) State

1 lusA

Reason for requesting manufacturer code

Please select all options that apply

D
D
D

To sell NIOSH-approved respirators manufactured by my company

To sell NIOSH-approved respirators manufactured by another approval holder
To obtain NIOSH approval for respirators that my company designs but that are manufactured by another company
for me

Public reporting burden of this collection of information is estimated to average 229 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid 0MB control number. Send comments regarding this burden to CDC/ATSDR Reports Clearance Officer, 1600
Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATIN: PRA(0920-0109). Do not send the completed form to this address.

Standard Application Form

Form Approved: 0MB No. 0920-0109

version 9. 20170407_1

G.

Product Details

For which type of respirator will you be seeking NIOSH approval?
List any subcontracted items here, and list the associated subcontractors in section E.

Product Description

Signed:

Dated

Print Name:
Return the completed questionnaire and photos of your manufacturing facility to:
NIOSH / NPPTL / CVSDB
ATTN: Records Room, B/141, Room 127
626 Cochrans Mill Road
Pittsburgh , PA 15236

Or via email to Records [email protected] or FAX to {412) 386-4051