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

Request for Renewal/NRTL Certification of Continued Compliance (Form IV)

Request for Renewal / NRTL Certification of Continued Compliance Attestation				OMB Control Number: 1218-0147 Expires: 01/31/2025
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/Country):				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 is 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/nrtllist.html
9. NRTL Site Information Update
a. Site Name	b. Type Site	c. Physical Address
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized Site
Update listing Remove Site
	HQ Site Recognized 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.
Part IV: 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; b) operate as a NRTL only within the NRTL’s approved scope of recognition (applicable test standards and sites), 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. A 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 USA 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 +1.202.693.1911.

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 web 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 mailing address, city, state, and postal code for the headquarters office of the NRTL (if different from the information in Block 2). 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 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 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 recognized NRTL 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. 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. Block 9a. Enter the name of the site as the NRTL wishes it to be displayed. Place a check next to 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 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.

Annex D-10