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| SECTION 1: APPLICANT Proposed specified product supplier details: [Must be a New Zealand Company or Resident] Name:................................................................................................................................... Street Address:...................................................................................................................... ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. Contact Person :.................................................................................................................... Position in Company :............................................................................................................. Telephone:.............................................................................................................................. Fax:....................................................................................................................................... E-mail:................................................................................................................................... Mailing address [include PO Box number if available]: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. Applicants URL:........................................................................................................(Optional) SECTION 2: PRODUCT Market Name of Product: ............................................................................................................................................ Full description of product...................................................................................................... ............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. Please include 2 copies of
the following with your application. Mfr's description/ Part No: ...................................................................................................... Hardware Version No:.............................................................................................................. Firmware Version No: ............................................................................................................. Year 2000 Compliant: ............................................................................................................. SECTION 3: MANUFACTURER Name of Manufacturer: ........................................................................................................... Street Address:...................................................................................................................... ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. Contact Person :..................................................................................................................... Position in Company :............................................................................................................. Telephone:............................................................................................................................ Fax:....................................................................................................................................... E-mail:................................................................................................................................... Mailing address [include PO Box number if available]: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. Manufacturers URL:....................................................................................................(Optional) Country of manufacture:............................................................................................................ SECTION 4: DECLARATION Full name of person authorised to sign on behalf of proposed specified product supplier ............................................................................................................................................... Position in Company:................................................................................................................ Signed: ................................................................................................................................... Date: ...................................................................................................................................... SECTION 5: CHORUS CONTACT DETAILS In all cases, this Application Form when completed should be forwarded directly to:- Ian McCulloch General enquires on Specified Product applications should be directed to: On receipt of this application you will be assigned an application number. Until an approval has been granted, all correspondence with MUST quote the Application number, and should be addressed to Ian McCulloch. Incomplete applications will NOT BE REGISTERED for processing. They will be placed on 'HOLD' until the application is complete. SECTION 6: FOR CHORUS USE ONLY Application Number: TSP............./ ............... Application Received: (date) .........../ .........../ ............ Information Complete: (date) .........../ .........../ ............ Application Acknowledged: (date) .........../ .........../ ............ |
