1. Product covered by this certificate	
Product Name:		
Item No:		
PO No:		Ages:		
Description:		
Tracking No:		

2. Applicable product safety standard(s) or regulation(s), if any, to which this product is being certified:	

3. U.S. importer or U.S. manufacturer certifying compliance of this product:	
Company Name:		
Address:		
City/State/Province/Zip:		
Phone:		

4. Contact information for the individual maintaining records of test results for this product:
	
Company Name:		
Contact:		
Address:		
City/State/Province/Zip:		
Phone:		
Email:		

5. Date and place where this product was manufactured:	
Manufacture City/Country:		
Month of Manufacture:		

6. Third-party testing laboratory on whose the certificate depends:	
Testing Lab Name:		
Address:		
City:		
State/Province/Zip:		Zip:		
Test Report Date:		
Test Report No.: