| Date | : | ____________________ | | Total No. of Pages | : | 10 |
| To | : | ____________________ | | Fax | : | _____________ |
| Attn | : | ____________________ | | Tel | : | _____________ |
| Instructions: Please provide all available information requested below. Return to: Section: | |
| Cord Sets & Power Supply Cord Equipment List | |
| Applicant Name & Address: | Contact Person: |
| | Tel. No.: |
| | Fax No.: |
| | E-mail: |
| Manufacturer Name & Address: | Contact Person: |
| | Tel. No.: |
| | Fax No.: |
| | E-mail: |
| For UL Engineer’s or Field Representative’s Use: Inspection Conducted by: File No: E Inspection Date: Project No.: | |
| Polarization and Continuity Test EquipmentReference: UL 817, Sec. 105 | |||
| Criteria | Comply with requirements? | Comments | |
| | Yes | No | |
| Ohmmeter available | Manufacturer: Model: | ||
| Light bulb and battery combination available | | ||
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