Form OSHA Form 5-30-5 OSHA Form 5-30-5 NRTL Initial Application, Expansion, and/or Scope Reduct

NRTL Initial Application, Expansion, and / or Scope Reduction Request							OMB No. 1218-0147 / Expires: xx/xx/xxxx
Part I: General Information
1. Legal Name of Applicant:
2. Applicant Headquarters Physical Address
a. Street Address:
b. City:				c. State/Province (as applicable):						d. Postal Code:
3. Applicant Headquarters Mailing Address (if different from physical address)
a. Street Address:
b. City:				c. State/Province (as applicable):						d. Postal Code:
4. Applicant Website Information
a. Website Address:
b. Web Address of online certification directory:
c. Web Address of online certification mark page:
5. Primary Point of Contact Information
a. Name:						b. Title/Position:
c. Telephone Number:						d. Fax Number:
e. Email Address:
6. Alternate Point of Contact Information
a. Name:						b. Title/Position:
c. Telephone Number:						d. Fax Number:
e. Email Address:
Part II: Reason for Request
7. Type of Request (Check all that apply)
a. Initial Recognition	b. Expansion – New Site(s)		c. Expansion – Additional Test Standards		d. Expansion – Supplemental Programs			e. Scope Reduction			f. Other
8. Brief Explanation of Request:

Part III: Site Information
Enter information as indicated for each site to be included in this request.
9. Applicant Site Information
a. Site Name and Contact Information	b. Site Information	c. Physical Address and Phone Numbers
Site Name:	Site Type HQ Site Recognized Site SNAP Site	Address:
Site POC:	Key Location HazLoc Testing LP Gas Testing Fire Suppression Medical Equipment	Site Phone Number(s):
POC Email:		POC Phone Number(s):
Site Name:	Site Type HQ Site Recognized Site SNAP Site	Address:
Site POC:	Key Location HazLoc Testing LP Gas Testing Fire Suppression Medical Equipment	Site Phone Number(s):
POC Email:		POC Phone Number(s):
Site Name:	Site Type HQ Site Recognized Site SNAP Site	Address:
Site POC:	Key Location HazLoc Testing LP Gas Testing Fire Suppression Medical Equipment	Site Phone Number(s):
POC Email:		POC Phone Number(s):
Site Name:	Site Type HQ Site Recognized Site SNAP Site	Address:
Site POC:	Key Location HazLoc Testing LP Gas Testing Fire Suppression Medical Equipment	Site Phone Number(s):
POC Email:		POC Phone Number(s):
Site Name:	Site Type HQ Site Recognized Site SNAP Site	Address:
Site POC:	Key Location HazLoc Testing LP Gas Testing Fire Suppression Medical Equipment	Site Phone Number(s):
POC Email:		POC Phone Number(s):
Site Name:	Site Type HQ Site Recognized Site SNAP Site	Address:
Site POC:	Key Location HazLoc Testing LP Gas Testing Fire Suppression Medical Equipment	Site Phone Number(s):
POC Email:		POC Phone Number(s):
Part IV: Verification of NRTL Requirements
The legal signatory’s initials in this part constitute the applicant’s certification of compliance / intent to comply with the NRTL Program requirements contained in 1910.7 and the terms of the NRTL’s recognition.
10. NRTL Requirement				Initials
For each specified item of equipment or material to be listed, labeled or accepted, the applicant has the capability (including proper testing equipment and facilities, trained staff, written testing procedures, and calibration and quality control programs) to perform:
Testing and examining of equipment and materials for workplace safety purposes to determine conformance with appropriate test standards; or
Experimental testing and examining of equipment and materials for workplace safety purposes to determine conformance with appropriate test standards or performance in a specified manner.
The applicant provides, to the extent needed for the particular equipment or materials listed, labeled, or accepted, the following controls or services:
Implements control procedures for identifying the listed and labeled equipment or materials;
Inspects the run of production of such items at factories for product evaluation purposes to assure conformance with the test standards; and
Conducts field inspections to monitor and to assure the proper use of its identifying mark or labels on products;
My organization is completely independent / impartial to influence from employers subject to the tested equipment requirements, and of any manufacturers or vendors of equipment or materials being tested for these purposes.
My organization maintains effective procedures for:
Producing creditable findings or reports that are objective and without bias; and
Handling complaints and disputes under a fair and reasonable system.
The applicant will comply / continues to comply with the terms of its letter of recognition and any special conditions, restrictions, or limitations identified in its most current scope of recognition.
Part V: Certification of Information
11. As legal signatory for _____________________________, the applicant, I attest that all statements and information contained in this form are correct to the best of my knowledge and are made in good faith. I also attest that my initials in Part III, “Verification of NRTL Requirements,” constitute the applicant’s certification of intent to comply / continuing compliance with the NRTL Program requirements contained in 1910.7. In addition, I attest that the applicant will: a) comply with all the policies, conditions, and requirements for recognition that OSHA imposes through its regulations, directives, and Federal Register notices of recognition; b) operate as an NRTL only within the NRTL’s approved scope of recognition (applicable test standards, sites, and programs), following the policies, procedures, structures, and practices described in the NRTL’s original or amended application accepted by OSHA, or in appropriate and approved revisions made after recognition; and c) promptly submit details to OSHA of any major changes in the NRTL’s operations.
12. Legal Signatory (type or print name):
13. Signature:			14. Date:

Paperwork Reduction Act Statement	OMB Control Number: 1218-0147
According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 160 hours for an initial application and no more than 24 hours for an expansion. This burden includes locating and assembling information required to complete the application. It may also include an on-site inspection / audit. The obligation to respond to this collection is voluntary. Information obtained from this form will be used to determine if the application and supporting information meets the requirements of the NRTL Program as outlined in 29 CFR 1910.7. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Labor, OSHA, Office of Technical Programs and Coordination Activities, Directorate of Technical Support and Emergency Management, 200 Constitution Avenue, NW, Room N3655, Washington, DC 20210.
Form Completion Directions
General Guidance
OSHA safety standards require that specified equipment and materials (products) be tested and certified for safety by an OSHA-recognized organization. OSHA’s Nationally Recognized Testing Laboratory (NRTL) Program fulfills this responsibility by recognizing the capabilities of mainly private sector testing organizations to test and certify such products for manufacturers. To be recognized, an organization must meet OSHA’s requirements. Initial recognition is granted if the application and an on-site audit of the organization demonstrate the applicant is completely has the capability to test and certify products for safety. An organization must have the necessary capability both as a testing laboratory and as a product certification body to receive OSHA recognition as an NRTL. Once recognized, OSHA reviews each NRTL’s activities to assure it continues to comply. The NRTL can also request an expansion of its recognition. This form, and its attachments, asks the NRTL to verify its general information as well as provide specific information related to its facilities and capabilities to meet NRTL Program requirements. Completing this form is entirely voluntary. Each applicant is free to submit an application for initial recognition or expansion using any form it chooses. However, OSHA will consider applications that do not contain the information requested in this form to be deficient and may delay or deny the request. An applicant that chooses to use this form for initial recognition or expansion must send: (1) this completed form; (2) any additional information it wishes to submit to demonstrate capabilities to meet NRTL Program requirements; and (3) payment to: Director Office of Technical Programs and Coordination Activities Directorate of Technical Support and Emergency Management Occupational Safety and Health Administration US Department of Labor 200 Constitution Avenue NW, Room N3655 Washington, DC 20210 Completed and signed forms and any accompanying documentation may also be scanned and emailed to [email protected]. For questions, contact the Office of Technical Programs and Coordination Activities at +1.202.693.2110

Part I Directions
Part I of this form provides basic information related to the applicant. The information will be used to update applicant records and information posted on OSHA’s NRTL webpage. Complete each bock as indicated below.
Block 1:	Enter the legal business name of the applicant as currently recognized or requested. Note: If the applicant wishes to use a name that is different from the name listed on OSHA’s NRTL page (see http://www.osha.gov/dts/otpca/nrtl/nrtllist.html), the applicant must submit a request for name change to OSHA’s NRTL Program office using the contact information listed above.
Block 2:	Enter the physical street address, city, state, and postal code for the headquarters office of the applicant. For international addresses, enter the province followed by the country name in Block 1c.
Block 3:	Enter the physical street address, city, state, and postal code for the headquarters office of the applicant. For international addresses, enter the province followed by the country name in Block 2c.
Block 4:	Block 4a. Enter the URL for the applicant’s home webpage. Block 4b. Enter the URL for the applicant’s online product certification listing. Note: if the applicant does not have a resource online, include a URL to a webpage that provides directions as to how a product certification may be obtained. Block 4c. Enter the URL to the webpage or online resource that explains the usage of the applicant’s certification mark as it applies to OSHA’s NRTL Program.
Block 5:	Enter contact information of the applicant’s primary point of contact. Include their name, title, telephone number, fax number, and email address.
Block 6:	Enter contact information of the applicant’s alternate point of contact. Include their name, title, telephone number, fax number, and email address.
Part II Directions
Please identify the reason for the application. For initial requests, ensure to include the Company Profile Worksheet. For initial requests and expansions of test standards, ensure to the Test Standard Worksheet.
Block 7:	In Block 7a through Block 7f, place a check next to each action that applies to this application. Place a check mark in Block 7d when applying for a supplemental program. This includes applications for recognition in the SNAP. For Block 7f, ensure a description of the action is included in Block 8.
Block 8:	Provide a brief description of the action being requested.
Part III Directions
Please enter the site name and address for each site to be included in this application. Use additional pages as required.
Block 9:	Block 9a. Enter the full name of the laboratory or SNAP site to be included with this application. Enter the point of contact (POC) for this site and the POC’s email address. Block 9b. Place a check next to the box that is most appropriate site type for the site being added in this application. Block 9c. Enter the complete physical address, site phone number and the POC phone number for the site being added. Be sure to include the name of the country and the telephone country code for international sites.

Part IV Directions
Part IV verifies and / or reaffirms the applicant’s commitment to compliance with all NRTL Program requirements. Each of the Block 10 questions must be initialed by the individual having signatory authority for the applicant.
Block 10:	The individual having signatory authority for the applicant should read each question carefully and place their initials in the box next to the question. Initialing the box verifies the applicant’s intent to comply / continued compliance with the NRTL Program requirements described in the question.
Part V Directions
Part V is the applicant’s certification that it will comply / continue to comply with the requirements of the NRTL Program as outlined in 29 CFR 1910.7, its letter of recognition, and supporting NRTL Program directive and guidelines. The blocks in Part V must be completed by the legal signatory for the applicant.
Block 11:	Enter the legal business name of the applicant. See note in Block 1 for additional information related to a name change for an NRTL.
Block 12:	Print or type the name of the individual having legal signatory authority for the applicant.
Block 13:	Enter the signature of the individual having legal signatory authority for the applicant
Block 14:	Enter the date the individual with legal signatory authority signed this document.

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OSHA Form 5-30.5 October 2013