OSHA Form 5-30-6 Request for Renewal/NRTL Certification of Continued Comp

Request for Renewal / NRTL Certification of Continued Compliance				OMB No. 1218-0147 / Expires: xx/xx/xxxx
Part I: General Information
1. Legal Name of NRTL:
2. NRTL Headquarters Physical Address
a. Street Address:
b. City:		c. State/Province (as applicable):				d. Postal Code:
3. NRTL Headquarters Mailing Address (if different from physical address)
a. Street Address:
b. City:		c. State/Province (as applicable):				d. Postal Code:
4. NRTL 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:
7. Additional Information:

Part II: Site Information
8. The information shown for each site listed on the OSHA NRTL Program webpage for the NRTL are complete and accurate. (Check only if no changes are needed to OSHA’s webpage listing of your sites).			a.
Note: A list of recognized sites is available at: http://www.osha.gov/dts/otpca/nrtl/#nrtls A list of SNAP sites is available at: http://www.osha.gov/dts/otpca/nrtl/snap_sites.html.
9. NRTL Site Information Update
a. Site Name	b. Type Site	c. Physical Address
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site
	HQ Site Recognized Site SNAP Site
New Site Update listing Remove Site

Part III: Verification of NRTL Requirements
The legal signatory’s initials in this part constitute the NRTL’s certification of continuing compliance 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 NRTL 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 NRTL 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 NRTL 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 IV: Certification of Information
11. As legal signatory for _____________________________, the NRTL, I attest that the NRTL requests to renew its recognition and 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 NRTL’s certification of continuing compliance with the NRTL Program requirements contained in 1910.7 and the terms of the NRTL’s recognition. In addition, I attest that the NRTL will: a) continue to comply with all the policies, conditions, and requirements for recognition that OSHA imposes through its regulations, directives, and Federal Register notices of recognition; b) continue to 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 5 hours per response. This burden includes locating and assembling information required to complete the renewal or certification, and completing the renewal / certification form. The obligation to respond to this collection is voluntary. Information obtained from this form will be used to determine if renewal of recognition will be granted to the applicant. 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’s recognition of a Nationally Recognized Testing Laboratory (NRTL) is valid for five years unless OSHA terminates recognition before the expiration of the five-year period. A recognized NRTL may renew its recognition by filing a renewal request not less than nine months or more than one year before the expiration of its current recognition. Each NRTL may apply for a continuation of its recognition status by following the procedures in 29 CFR 1910.7, App. A.II.C. This form serves a Renewal Request and as a Certification of Continued Compliance with NRTL Program requirements. The form asks the NRTL to verify its general information as well as verify its compliance with NRTL Program requirements. Completing this form is entirely voluntary. Each NRTL is free to apply for renewal or certify continued compliance with the terms of its recognition and 29 CFR 1910.7 in any form it chooses. However, OSHA will consider a renewal request or certification that does not contain the information requested in this form to be deficient and may delay or deny the renewal. An NRTL that chooses to use this form for a renewal request or to certify its continued compliance with the terms of its recognition and 29 CFR 1910.7 must send: (1) this completed form; (2) any additional information it wishes to submit to demonstrate its compliance with the terms of its recognition and 29 CFR 1910.7; 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 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 NRTL. The information will be used to update NRTL records and information posted on OSHA’s NRTL webpage. Complete each bock as indicated below.
Block 1:	Enter the legal business name of the NRTL as currently recognized by OSHA. Note: If the NRTL 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 NRTL 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 NRTL. 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 NRTL. For international addresses, enter the province followed by the country name in Block 2c.
Block 4:	Block 4a. Enter the URL for the NRTL’s home webpage. Block 4b. Enter the URL for the NRTL’s online product certification listing. Note: if the NRTL 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 NRTL’s certification mark as it applies to OSHA’s NRTL Program.
Block 5:	Enter contact information of the NRTL’s primary point of contact. Include their name, title, telephone number, fax number, and email address.
Block 6:	Enter contact information of the NRTL’s alternate point of contact. Include their name, title, telephone number, fax number, and email address.
Block 7:	Enter any additional information the NRTL would like to include with the application for renewal. Additionally, provide a description of any enclosures to the renewal application that the NRTL has included with their request.
Part II Directions
Please verify that the site name and address for all recognized sites and SNAP sites identified on the OSHA NRTL website are accurate. If no changes are necessary, please check the box indicating that you reviewed this information on the OSHA NRTL website, and that it is complete and accurate. If changes are necessary, please update the information as outlined below. Use additional pages as required.
Block 8:	Review the listing that OSHA has for your NRTL sites (both recognized and SNAP sites) using the web addresses listed in Block 8. If the listing is correct and complete, place a check in Block 8a and proceed to Block 10. If additions or corrections are required, proceed to Block 9.
Block 9:	Update information for each site that is not listed, sites where information listed on OSHA’s NRTL site webpage is incorrect, or sites that need to be removed. Note: The purpose of this section of the form is to update information related to previously recognized sites and SNAP sites. Do not use this form to add new sites that have not previously been recognized. To have new sites considered for formal recognition, submit an expansion application in accordance with Appendix II B. of 29 CFR 1910.7. To add new SNAP sites, submit formal notification as outlined in SNAP Program guidelines at http://www.osha.gov/dts/otpca/nrtl/snap.html. Block 9a. Enter the name of the site as the NRTL wishes it to be displayed. Place a check next to New Site, Update Listing, or Remove Site as applicable.
Block 9 (continued):	Block 9b. Place a check next to the box that is most appropriate site type for the site being added or updated. Block 9c. Enter the complete physical address for the site being added or updated. Be sure to include the name of the country for international sites.
Part III Directions
Part III verifies and reaffirms the NRTL’s commitment to compliance with all NRTL Program requirements and the NRTL’s conditions of recognition. Each of the Block 10 questions must be initialed by the individual having signatory authority for the NRTL.
Block 10:	The individual having signatory authority for the NRTL should read each question carefully and place their initials in the box next to the question. Initialing the box verifies the NRTL continues to comply with the NRTL Program requirements described in the question.
Part IV Directions
Part IV is the NRTL certification that it will 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 IV must be completed by the legal signatory for the NRTL.
Block 11:	Enter the legal business name of the NRTL as currently recognized by OSHA. See note in Block 1 for additional information related to a name change for the NRTL.
Block 12:	Print or type the name of the individual having legal signatory authority for the NRTL.
Block 13:	Enter the signature of the individual having legal signatory authority for the NRTL
Block 14:	Enter the date the individual with legal signatory authority signed this document.

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OSHA Form 5-30.6 October 2013