APPLICATION FOR PRODUCT’S CONFORMITY ASSESSMENT

Dear Sirs, please send us the below information to be used in preparation of our offer for product’s conformity assessment. Completion of the application does not mean an obligation to use our services, and no fee will be charged thereupon. Information contained in the application will be treated as confidential.

Information on certification requirements as well as Applicants’ rights and responsibilities is available at www.prs.pl.

General information
Applicant:	Adress:
Applicant status:
manufacturer 1)	brand manufacturer 2)	authorised representative 3)
1) manufacturer - means any natural or legal person who manufactures PPE or has it designed or manufactured, and markets it under his name or trademark;
2) brand manufacturer - a particular group of manufacturers, a physical or legal person who sells a product under his name or trademark

designed and/or manufactured by the actual manufacturer, identical in design and technology to the product introduced into

the sales by the actual producer

3) authorised representative - means any natural or legal person established within the Union who has received a written mandate from a manufacturer to act on
his behalf in relation to specified tasks
Registered in (please specify register name and its location):	under the entry (please specify assigned registry number):
VAT No.:	Share capital (if applicable to form of business):
Manufacturer (if other than Applicant):
Manufacturer's name:	Adress:
Registered in (please specify register name and its location):	under the entry (please specify assigned registry number):
VAT No.:	Share capital (if applicable to form of business):
Product to be assessed for conformity with EU Directives (please specify a name of the product – its proper name, the product type, etc., according to the product label. Given product name will be binding on each stage of the conformity assessment):
EU Directive:	Modul:	Readiness for assessment (please specify the date):
MED	PPER	PED	SPV	EMC
List of standards and regulations applicable to the product:
Approvals, certificates held by Applicant/manufacturer:

Applicant’s declarations:
I confirm that I have acknowledged and understood general requirements concerning product certification system.

I confirm that an application for conformity assessment was not placed with another notified body.

I undertake to comply with all requirements regarding application for product certification.

I undertake to supply complete technical documentation of the product and all information indispensable for assessment of the product.

I confirm that the product presented for certification was not a subject of cooperation between the Applicant and Polish Register of Shipping (e.g. at designing stage).

Attachments to the Application (if applicable)
Item	Name	Attached document	Remarks
a)	Technical documentation of the product enabling conformity assessment performance according to the requirements of the directive and other applicable standards
b)	Tests reports (if tests were performed)
c)	Documentation of production quality assurance system
d)	Risk analysis and assessment
e)	Approvals, certificates held by the Manufacturer
f)	Calculations
g)	List of applied materials and components
h)	Copy of the company registration document
i)	Other documents
Additional information
Has the Applicant received any claims concerning the products covered by the scope of the certificate within its validity period (it concerns extension, prolongation, recertification)?	YES
NO
N/A
Does the Applicant have any connections (e.g. Business liaisons) with the provider of tests reports which are enclosed to this Application (if applicable)?	YES
NO
N/A
Applicant’s authorized contact person:
The Applicant shall familiarize the person authorized for contact with the Information Clause below.
First and last name:	Position in company:
Tel:	Email:
Signature:	Date:
PART FOR LEGAL ENTITY:

I agree to the use by Polski Rejestr Statków S.A. seated in Gdansk of telecommunications terminal equipment and automatic calling systems (e.g. telephone, e-mail), which we are a user of, for the purposes of direct marketing, in accordance with art. 172 of Telecommunications law and sending commercial information.

PART FOR NATURAL PERSONS (ALSO ONE-MAN BUSINESSES):

Information on the right to withdraw consent

You have the right to withdraw your consent to the processing of your personal data at any time. Withdrawal of consent will not affect the lawfulness of the processing which was carried out on the basis of your consent before its withdrawal.

Consent No. 1 I agree to the processing of my personal data provided in this form by Polski Rejestr Statków S.A. seated
in Gdansk for marketing purposes.

Consent No. 2 I agree to the use by Polski Rejestr Statków S.A. seated in Gdańsk of automatic calling systems
or telecommunications terminal equipment, which I am a user of, for the purposes of direct marketing, in accordance
with art. 172 of Telecommunications law.

Consent No. 3 I agree to receive business information by electronic means from Polski Rejestr Statków S.A. seated in Gdańsk, in accordance with art. 10 of the Act on the provision of electronic services.

Information Clause for natural persons (also one person companies)
and also for persons authorized for contact indicated in p. 12 of this form

In accordance with the regulation of art. 13 item 1 and item 2and art. 14 item 1 and 2 of the Regulation EU 2016/679 of European Parliament and the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation), (Official Journal of the European Union 2016.119.1 of 04.05.2016), called further GDPR, Polski Rejestr Statków S.A. seated in Gdańsk, called further the Company, informs that:

Personal Data Controller

Polski Rejestr Statków S.A. with its headquarters in Gdańsk (address: al. gen. Józefa Hallera 126, 80-416 Gdańsk,
tel.: + 48 058 346 17 00, + 48 058 751 11 00, e-mail: mailbox@prs.pl) is the Controller of your personal data.

Data Protection Officer

The Company has designated the Data Protection Officer, whom you can contact with regarding any issue on protection of your personal data by tel.: + 48 058 751 12 97, e-mail: iod@prs.pl or in writing to the address of the Company’s Head Office, indicated above.

Purpose and basis of data processing

Your personal data are necessary for preparation of an offer and a draft of a contract, which you are the Party to. In this respect your personal data will be processed on the basis of the provision of art. 6, item 1 (b) of GDPR for correct agreement execution in accordance with Parties intentions. Providing your personal data is necessary to prepare the offer and a draft of the contract. Providing data is voluntary, but the consequence of not providing personal data will be the inability to present the contract, conclude the contract / obstruction in the proper implementation of the contract.

In case of Consent 1, 2 and 3 your personal data will be processed on the basis of the provision of art. 6, item 1 (a) of GDPR, i.e. your consent for marketing purposes, selection of services to your interests or to research your satisfaction with services provided.

If you are only a person indicated for contact according to point 12 of the form above, your data indicated in point 12 above will be processed due to the legitimate interest of the Controller, namely to prepare the offer and a draft of the contract with its possible conclusion with the entity indicated in the form above who provided us with your data. The Controller's interests are focused on developing the commercial and business offer as well as the economic profit while respecting your privacy and rights, including processing your personal data to the minimum extent necessary to achieve this goal. Your data has been formally provided to us by the entity indicated in the form above.

The Company does not intend to process your personal data for the purpose other than that for which your data have been collected. Where the data need to be processed for another purpose, the Company shall inform you thereon before planned processing and shall provide any other appropriate information in this respect.

Right to object

You have the right to object at any time against processing your data by the Company. The Company shall no longer process
the personal data for that purpose, unless the Company demonstrates compelling legitimate grounds for the processing your personal data which override your interests, rights and freedoms or your data will be necessary to determine, pursue or defend legal claims.

If your personal data are processed for direct marketing purposes, you have the right to object at any time to processing of your personal data for such marketing, including profiling to the extent that it is related to such direct marketing. In such situation, your data will no longer be processed for such purposes.

Period of data storage

In the case of points II.1 and II.3 above, your personal data will be processed during the period of preparation and validity
of the offer, until the conclusion of the contract.

In the case of point II.2 above, your personal data will be processed until you object to their further processing or until it is determined that your personal data have become outdated.

Data recipients

The recipients of your personal data will be employees and co-workers of Polski Rejestr Statków S.A. seated in Gdańsk. Your personal data may be disclosed to the entities from our capital group (subsidiaries) and branches (domestic and foreign).

Our subcontractors (processors), such as accounting, law, IT firms, marketing agencies may also have access to your data.

The Controller does not transfer your data to third countries or to international organizations.

Rights of persons providing the data

According to GDPR, you have the below rights:

right to access to own data and to obtain their copy;

right to rectification (correction) of own data;

right to erase data and to restrict data processing;

right to object to data processing;

right to data portability;

right to lodge a claim with a supervisory authority.

According to p. 1. 6 above, you have the right to lodge a claim with a supervisory authority, in particular in the Member State of your habitual residence, place of work or with the President of the Office for Personal Data Protection (PUODO) that is Polish supervisory authority, if you consider that processing of your personal data infringes GDPR regulations.

Information on voluntary provision of data

Providing data for preparation of the offer by the Controller and concluding the contract is voluntary, however, it is necessary to prepare the offer and a draft contract that you are interested in.

In case of the Consents 1,2 and 3 providing personal data is voluntary.

Automated decision-making

Within the process of the contract conclusion and execution, the Company does not make decisions in automated manner based on data provided by you.

Your data shall not be processed automatically, including profiling. In accordance with the provision of art. 4 (4) of GDPR, "profiling" means any form of automated processing of personal data consisting of the use of personal data to evaluate certain personal aspects relating to a natural person, in particular to analyse or predict aspects concerning that natural person's performance at work, its economic situation, health, personal preferences, interests, reliability, behaviour, location or movements.

Form. 1/PCW-01

Ed. 2020-04-15

1/4

Aneta Wojtkowiak-Iwanow

2020-04-21

rds-a.wojtkowiak