Form 0920-0109 Standard Application Form

Standard Application Form
I

version 9. 20190409

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Form Approved: 0MB No.
0920-0109 Exp. Date: xx/xx/20xx
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Before completing this document, please review the instructions as well as the NIOSH Standard Application Procedure for the Approval of
Respirators under 42 CFR 84 for the specific class of respirator being submitted.

Section C.1: Project Reference Numbers
(C.1.A) What is your NIOSH-assigned Manufacturer Code?

rves

(C.1.B) Does the manufacturer hold a current approval?

(i'No

(C.1.C) Assign an unique reference number to this application, as directed by NIOSH

Section C.2: Type of Application
(C.2.A) Type of Application
(i'New

r Extension

r Quality Assurance Approval

r Correlation Testing Only

Refer to Section C.8 for Resubmittal

Section C.3: Manufacturer
(C.3.A) Manufacturer Name

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.

Note: By choosing “Combination Air-Purifying and Atmosphere-Supplying”, you indicate that all of the respirators you will
describe perform both functions