Form 001C Manufacturing Registration Application

U.S. Election Assistance Commission
OMB Control # XXXX-XXXX

Manufacturer Registration Application

1. Manufacturer Information
Legal Name of Business:
Address of Business:
City:
Organization Type:

State:
Corporation

Partnership

Sole Proprietor

ZIP Code:
Other:

(please explain)

Names of Officers, Board of
Directors, and all Partners:

Name of Individual or Entity
with Controlling Ownership
in the Manufacturer:

2. Management Representative
First Name:

Title:

Last Name:

Middle Initial:

Address:
City:

State:

Email:

Phone Number:

ZIP Code:

3. Technical Representative
First Name:

Title:

Last Name:

Middle Initial:

Address:
City:

State:

Email:

Phone Number:

Form EAC 001C

ZIP Code:

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4.

Briefly describe your quality system (e.g. ISO 9001). Provide your written policies supporting this
description as a part of this application:

5.

Briefly describe your internal requirements for managing change control/version control for both
hardware/firmware and software. Provide your written policies supporting this description as part of this
application:

6.

Briefly describe your document retention requirements. Provide your written policies supporting this
description as part of this application:

7.

List the name, address, city, state/province, country, postal code, and phone number for all facilities
used by your company to manufacture your voting system product, and the name, title, address,
email address, and phone number for a person at each facility:

Form EAC 001C

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8. Manufacturer Certification Agreement:
To maintain a voting system certification under the Election Assistance Commission (EAC) program, the
manufacturer must agree to:
1. Represent a voting system as certified only when it is authorized by the EAC and consistent with the
procedures and requirements of the Testing and Certification Program Manual (the Manual).
2. Produce and permanently affix an EAC certification label to all production units of the certified system.
3. Notify the EAC of changes to any system previously certified by the EAC pursuant to the requirements of
the Manual.
4. Permit an EAC representative to verify manufacturer quality control by coordinating with EAC efforts to test
and review fielded voting systems consistent with Section 8.6 of the Manual.
5. Permit an EAC representative to verify manufacturer quality control by conducting periodic inspections of
manufacturing facilities consistent with Chapter 8 of the Manual.
6. Cooperate with any EAC inquiries and investigations into a certified system's compliance with voting system
standards or the procedural requirements of the Manual.
7. Report to the Program Director any known malfunction of a voting system holding a current EAC
Certification. A malfunction is defined as a failure of the voting system, not caused by operator or
administrative error, which causes the system to fail or otherwise not operate as designed.
8. Certify that the manufacturer is not barred or otherwise prohibited by statute regulation or ruling from
doing business in the United States.
9. Adhere to all procedural requirements of the Manual.
Signature (handwritten or digital)
Title:
Date:

EAC Use Only
Manufacturer's
Designation:
Notes:

Form EAC 001C

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Instructions:
This form provides for the registration of voting system manufacturers. Registration is the initial required step
in the EAC Voting System Certification Program. This form is prescribed by Section 2.4 of the Manual. For
more information on registration requirements please see Section 2.4 of the Manual.
This form is generally self-explanatory however the numbers and the instructions below correspond to the
numbered sections of the form.
1. Manufacturer Information.

Names of Officers and/or Board of Directors and/or all Partners: Ensure that all individuals are identified by
name, and title.
Name of Individual or Entity with Controlling Ownership in the Manufacturer: Ensure that the controlling
individual is properly named, and an address is provided.
2. Management Representative.

Please provide the name and information requested for the designated Manufacturer Representative pursuant to
Section 2.3 of the Manual.
3. Technical Representative.

Please provide the name and information requested for the designated Technical Representative pursuant to
Section 2.3 of the Manual.
4, 5 and 6
Provide the information listed and attach to your submission the written documentation required by Section
2.3.1 of the Manual.
7. Manufacturer Certification Agreement
Manufacturers are required to take or abstain from certain actions consistent with the certification program. Your
concurrence to these requirements is signified by affixing the signature of the manufacturer representative.
This information is required for the EAC to provide for the certification of voting systems as required by 42 U.S.C. Section
15371. This information will be used solely to administer the EAC Testing and Certification Program. This program is voluntary,
however, individuals who wish to participate must meet the requirements of the Program. This information will be made public
consistent with the requirements of the Freedom of Information Act, the Trade Secrets Act, and any other applicable Federal law
or regulation. Public reporting burden for this collection of information is estimated to average about 9.75 hours for
completion of this form. This estimate includes the time for reviewing the instructions, gathering information, and completing
the form. Send comments regarding this burden estimate to the Testing and Certification Program Director, Election
Assistance Commission, 633 3rd Street NW Suite 200, Washington DC 20001. Notwithstanding any other provision of law, no
person is required to respond to, nor shall any person be subject to a penalty for failure to respond to, or comply with, a
collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information
displays a currently valid OMB Control Number.

Form EAC 001C

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