United States Election Assistance Comittee

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Manufacturer Registration Form

OMB Control #3265-0004

Instructions

This form provides for the registration of voting system manufacturers. Registration is the initial required step in the EAC Voting System Certification Program. This form is prescribed by Section 2.4 of the Manual. For more information on registration requirements please see Section 2.4 of the Manual.

This form is generally self-explanatory however the numbers and the instructions below correspond to the numbered sections of the form.

1. Manufacturer Information.

Names of Officers and/or Board of Directors and/or any and all Partners: Ensure that all individuals are identified by name and title.

Name of Individual or Entity with Controlling Ownership in the Manufacturer: Ensure that the controlling individual is properly named and an address is provided.

2. Management Representative.

Please provide the name and information requested for the designated Manufacturer Representative pursuant to Section 2.3 of the Manual.

3. Technical Representative.

Please provide the name and information requested for the designated Technical Representative pursuant to Section 2.3 of the Manual.

4, 5 and 6

Provide the information listed and attach to your submission the written documentation required by Section 2.3.1 of the Manual.

7. Manufacturer Certification Agreement.

Manufacturers are required to take or abstain from certain actions consistent with the certification program. Your concurrence to these requirements is signified by affixing the signature of the manufacturer representative.

Manufacturer Registration Form

indicates required field

1.  Manufacturer Information

Legal name of Business:
Address of Business:
City:
State:
Zip Code:
-
Organization Type:
Name of Officers and/or Board of Directors and/or any and all Partners:
Name of Individual or Entity with Controlling Ownership in the Manufacturer:

2.  Management Representative

First Name:
Middle Initial:
Last Name:
Title:
Address:
City:
State:
Zip Code:
-
Email:
Phone Number:
Fax Number:

3.  Technical Representative

First Name:
Middle Initial:
Last Name:
Title:
Address:
City:
State:
Zip Code:
-
Email:
Phone Number:
Fax Number:
4. Briefly describe your quality system (e.g. ISO 9001). Provide your written policies supporting this description as a part of this application:
Quality Control Document:
(.doc, .docx, .xls, .xlsx, .ppt, .pptx, .rtf, .txt, .csv, .pdf)
5. Briefly describe your internal requirements for managing change control/version control for both hardware/firmware and software . Provide your written policies supporting this description as part of this application:
Change Control Document:
(.doc, .docx, .xls, .xlsx, .ppt, .pptx, .rtf, .txt, .csv, .pdf)
6. Briefly describe your document retention requirements . Provide your written policies supporting this description as part of this application:
Document Retention Document:
(.doc, .docx, .xls, .xlsx, .ppt, .pptx, .rtf, .txt, .csv, .pdf)
7. Please list the Name, Street Address, City, State/Province, Country, Postal Code, and Telephone Number for all facilities used by your company to manufacture your voting system product:

To maintain a voting system certification under the Election Assistance Commission (EAC) program, the manufacturer must agree to:

1. Represent a voting system as certified only when it is authorized by the EAC and consistent with the procedures and requirements of the Testing and Certification Program Manual (the Manual).

2. Produce and permanently affix an EAC certification label to all production units of the certified system.

3. Notify the EAC of changes to any system previously certified by the EAC pursuant to the requirements of the Manual.

4. Permit an EAC representative to verify manufacturer quality control by coordinating with EAC efforts to test and review fielded voting systems consistent with Section 8.6 of the Manual.

5. Permit an EAC representative to verify manufacturer quality control by conducting periodic inspections of manufacturing facilities consistent with Chapter 8 of the Manual.

6. Cooperate with any EAC inquiries and investigations into a certified system's compliance with voting system standards or the procedural requirements of the Manual.

7. Report to the Program Director any known malfunction of a voting system holding a current EAC Certification. A malfunction is defined as a failure of the voting system, not caused by operator or administrative error, which causes the system to fail or otherwise not operate as designed.

8. Certify that the manufacturer is not barred or otherwise prohibited by statute regulation or ruling from doing business in the United States.

9. Adhere to all procedural requirements of the Manual.

Manufacturer Certification Agreement Signature:
(.jpg, .gif, .png, .bmp, .tif)
Manufacturer Certification Agreement Title:
Manufacturer Certification Agreement Date:

This information is required for the EAC to provide for the certification of voting systems as required by 42 U.S.C. Section 15371. This information will be used solely to administer the EAC Testing and Certification Program. This program is voluntary, however, individuals who wish to participate must meet the requirements of the Program. This information will be made public consistent with the requirements of the Freedom of Information Act, the Trade Secrets Act, and any other applicable Federal law or regulation. Public reporting burden for this collection of information is estimated to average about 9.75 hours for completion of this form. This estimate includes the time for reviewing the instructions, gathering information and completing the form. Send comments regarding this burden estimate to the Testing and Certification Program Director, Election Assistance Commission, 1201 New York Avenue, NW, Suite 300, Washington, DC 20005. Notwithstanding any other provision of law, no person is required to respond to, nor shall any person be subject to a penalty for failure to respond to, or comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number.