Form EAC 001C EAC 001C Manufacturer Registration Application

U.S. Election Assistance Commission

Print Form

Manufacturer Registration Application

Submit by Email
OMB Control # 3265-0004

1. Manufacturer Information
Legal Name of Business:
Address of Business:
State AL

City:
Organization Type:

Corporation

Partnership

ZIP Code:

Sole Proprietorship

Other

Names 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:

Title:

Last Name:

Middle Initial:

Address:
State AL

City:
ZIP Code:

Email:

Phone Number:

FAX Number:

3. Technical Representative
First Name:

Title:

Last Name:

Middle Initial:

Address:
State AL

City:
ZIP Code:

Email:

Phone Number:

FAX Number:

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4. Briefly describe your quality system (e.g. ISO 9001). Provide your written policies supporting this
description as a part of this application :

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 :

6. Briefly describe your document retention requirements . Provide your written policies supporting
this description as part of this application :

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 :

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8. Manufacturer Certification Agreement:
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.

Signature:

Title:
Date:

EAC Use Only

Manufacturer's
Designation:
Notes:

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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 wriiten documentation required by Section 2.3.1 of the
Manual.
7. Manufacurer 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.
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, 1225 New York Avenue, N.W., Suite 1100, 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.

Form EAC 001C

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