To be filled in by LR-Nederland

File no.: .

Order no.: ....

Application Form Pressure Equipment

Pressure Equipment Directive PED 2014/68/EU
Not intended for application of assemblies and inspection for putting into service; see applicable application forms. This
request form is not a contract.

APPLICANT (legal manufacturer, as stated in the PED)

Company Name: Contact person:

Address: City:

Country: VAT number:

The manufacturer requests a conformity assessment of the equipment according to the module (or combination
of modules):

A2 Supervised checks at random interval

B EU-Type examination production type
B EU-Type examination design type
C2 Supervised checks at random interval in relation to conformity to type
F Pressure equipment verification, based on EU-Type examination
G EU unit verification
H1 EU-design examination and special surveillance of the final assessment*
ad B Issue of an addition to a Certificate of EU-Type examination production type**
ad B Issue of an addition to a Certificate of EU-Type examination design type**
ad H1 Issue of an addition to a Certificate of EU-design examination**

*For module H1 please note certificate no. and scope:

**In case of an addition: it concerns LR registration no.:

The manufacturer declares that a similar request for EU-design or type-examination, according to modules
B, G or H1, has not been lodged with any other notified body.

Place: Date: Signature:

Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
Page 1 of 6
 To be filled in by LR-Nederland

File no.: .

Order no.: ....

Application Form Pressure Equipment

Pressure Equipment Directive PED 2014/68/EU
SUBCONTRACTOR
If above mentioned manufacturer is not the fabricator of the pressure equipment, the equipment is fabricated by:

Name: Address:

City: Country:

END USER (if known)

Name: Address:

City: Country:

Type of pressure equipment

(PED, art. 4): (par. 1.a) Vessel (par. 1.c) Piping
(par. 1.b) Boiler (TS>110C) (par. 1.d) Safety accessory
(par. 1.d) Pressure accessory

DATA OF THE PRESSURE EQUIPMENT

Description / type:

Production: Single item Serial production

Number of the same type / design or related to

one family:

Fabrication / serial number(s):

Reference (project no. / PO no. / etc.):

Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
Page 2 of 6
 To be filled in by LR-Nederland

File no.: .

Order no.: ....

Application Form Pressure Equipment

Pressure Equipment Directive PED 2014/68/EU

Pressure equipment data

Item number / reference of the equipment

Name of the chambers

Capacity L
(vessel)
Heated surface m2

Nominal diameter (piping) DN

Inside diameter mm 1)
Max /min. allowable pressure PS bar 2)

Max./min. allowable temperature TS C 2)

Fluid
(full name and/or composition)

Phase of the fluid at the maximum allowable

temperature TS: (Gas (G), liquefied gas (G), gas
dissolved under pressure (G), vapour (G), liquid (L))
Atmospheric boiling point of the fluid(s) C

Vapour pressure at the maximum allowable

temperature bar
Fluid group according PED, art. 13
1 2 1 2 1 2 1 2
Applied table according PED, art. 4, par.1 / PED,
annex II
Category of chamber

Equipment category according PED, annex II (art. 13)

Remarks

Design basis Harmonized standard ASME VIII, Div. 1

EN 13445
Dutch Rules for Pressure vessels PD 5500
(RToD)
Other:

Danger class/construction category/joint efficiency

according to chosen design basis

1) If DN is not known inside diameter shall be stated in mm.

2) In case of a combination of pressure and temperature, please fill in one column for each combination. Clarification can de
added under remarks.

Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
Page 3 of 6
 To be filled in by LR-Nederland

File no.: .

Order no.: ....

Application Form Pressure Equipment

Pressure Equipment Directive PED 2014/68/EU

DOCUMENTS TO BE SUBMITTED WITH THE APPLICATION

MODULES Ref. to
remarks
A2 B* B* C2 F G H1*
Prod. Design

General (8) (8) (8)

Application form
(1) (1) (1) (1) (1) (1) (1)
Result of the hazard analyses
(4) (4) (4) (4)
Design and fabrication drawings and other relevant technical
documentation (2) (1) (1) (2) (2) (1) (1)
Particular Material Appraisal
(4) (4) (4) (4)
List of applied harmonised standards

Design calculations / results of examination related to the design

(1) (1) (1) (1)
Copy or number of the Certificate of EU-Type examination module
B production type (1)
Copy or number of the Certificate of EU-Type examination module
B production or design type (1)
Copy of the certificate of the QA system module H
(3)
Qualifications / approvals of the methods for permanent joints
(3) (3) (3)
Qualifications / approvals of personnel for permanent joints
(3) (7) (3) (3)
Qualifications / approvals for personnel for NDT
(3) (7) (3) (3)
Production scheme
(5) (5) (5)
Concept test and inspection plan
(3) (3) (3) (3) (3) (3)
Required information
Required information, included with this application (checkmark to be filled in by the applicant)

* In case of an application for an addition to an EU design or type approval, reference can be made to information
supplied with a previous application, as far as this is still valid.
(1) If not included, the application cannot be processed.
(2) Information for quotation purposes.
(3) Not necessary to send in with this application. Can be examined during the inspection phase.
(4) Design appraisal can be started, but not finalised without this information. EU-Certificate can only be issued after
this information has been made available.
(5) Required for planning visits.
(6) Information not mandatory to include in the application, but recommended in order to avoid complication
during the inspection phase.
(7) If not made available a note on the Certificate of EU-design examination will be placed, stating that this
certificate is only valid, after the missing information being approved by a notified body.
(8) When applying for an addition to a Declaration of EU-design examination, the original Declaration and possible
addition shall be included with the application.

Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
Page 4 of 6
 To be filled in by LR-Nederland

File no.: .

Order no.: ....

Application Form Pressure Equipment

Pressure Equipment Directive PED 2014/68/EU

Remarks

Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
Page 5 of 6
Appendix to:
Application Form Pressure Equipment
Pressure Equipment Directive PED 2014/68/EU

This appendix contains useful customer information for the inspection phase.
In particular it describes the documents needed to complete inspection requirements.
Please note that the documents mentioned will need to be available during (final) inspection.
A copy of said documents will have to be available for our surveyor.

This page should not be submitted with the application form

Documents to be submitted to Lloyds Register surveyor
Modules
A2 B B C2 F G H1
prod. design
Complete Design Appraisal Document
(DAD) incl. Visit Report. Preferably the
original document.
DAD will be returned to you as certificate attachment
Signed and completed Test and Inspection
Plan

List of welders- and welding procedure

qualifications * * *

List of materials * * *

(List and/or overview of ) NDT * * *

(List of) NDT personnel Qualifications. * * *

EU Type-, or Design examination

Certificate

(concept) Declaration of Conformity

(concept) Operating Instructions

* Possible, depending on the nature & extend of surveillance / monitoring. (Documents should be present,
copy can be requested at the surveyors discretion)

Lloyds Register, its affiliates and subsidiaries and their respective officers, employees or agents are, individually and collectively, referred to in this clause
as the Lloyds Register Group. The Lloyds Register Group assumes no responsibility and shall not be liable to any person for any loss, damage or
expense caused by reliance on the information or advice in this document or howsoever provided, unless that person has signed a contract with the
relevant Lloyds Register Group entity for the provision of this information or advice and in that case any responsibility or liability is exclusively on the
terms and conditions set out in that contract.
FORM-S-101 (2016-07)
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