Bureau Veritas Consumer Products Services Vietnam Ltd.

TEST REQUEST FORM

Lot C7-C9, Conurbation 2, Cat Lai Industrial Zone, District 2, HCMC, VN

Tel: 84-28-37421604~6 - Fax: 84-28-37421603 - Email: [email protected]
ALL FIELDS WITH ASTERISK ** AS MANDATORY INFORMATION, MUST BE COMPLETED
A. SERVICE REQUIRED **
Regular (5-7 Working Days or per Rush (2-3 Working Days - 40% Priority (Next working day -
testing nature) Surcharge) 100% Surcharge)
Re-Test (if retest, please write previous
First Time Test Previous Report#
report# at beside section)
CPC/GCC (Children Product Certificate/ General Conformity Certificate) request ($25/each CPC/GCC). Please also fill in Additional
form (page 2) for Importer and Person Maintaining Records
Quotation before testing (test will be placed on hold until receiving confirmation) or testing per provided Quotation#

B. APPLICANT (VENDOR/SUBMITTER) INFORMATION: (We will use company name/address/ contact person info of this
section to show on report)**
Magnussen Home (as below) Factory (factory to provide)

Company Name: MAGNUSSEN HOME FURNISHINGS

Address & Post Code: 66, Hincks Street Suite 1, New Hamburg, Ontario, Canada
Contact Person: Roxie Tax Code :
Tel: (+84) 792 758 284 Fax: Email : [email protected],
CC Reports To Email 1:[email protected] Email 2: [email protected]
Email 3:

BILLING INFORM ATION FOR ISSUING VAT INVOICE Report to Applicant:** Yes No (If no,
Magnussen Home (as below) Factory please fill in “Report To” below)

Company Name: CÔNG TY TNHH MAGNUSSEN LOGISTIC Report To (Company name): applicant and factory
Address: Lot A8(Group A4),D9 Street,Rach Bap
Address & Post Code: Số 158 Ngô Gia Tự, Phường Chánh Nghĩa, TP. Industrial park,An tay ward ,Ben Cat city,
Thủ Dầu Một, Bình Dương Binh Duong province,Viet Nam

Contact Person: Roxie Tax Code : 3 7 0 0 9 3 8 6 4 7 Contact Person:

Tel: (+84) 792 758 284 Fax: Email : [email protected], Tel/Fax:
CC Reports To Email 1:
Email 2: Email 3: E-mail:

C. PRODUCT INFORMATION: (if any information is not available or not needed to show on test report, please leave blank)
Sample Description /
B5991 color panel ,GLIDE,HANDLE ,KNOB
Product Name**
Item ID/SKU# B5991 Date of Production
Line Buyer/Client
Item Collection Bedrom group Country of
Destination/Market: US
**
Manufacturer name* JIA CHENG VIET NAM CO.,LTD P.O. #
Color As sample Wood Type or
specie/ Material:
Agent/Vendor Name* Magnussen Home Furnishings Quantity of
sample(s) 1
submitted:
Group SKU# Fiber content (for

BV-Magnussen-CPSD-HL-TRFS-VN-TRF-V00 Page 1 of 6 SEP-2024

 Bureau Veritas Consumer Products Services Vietnam Ltd.
TEST REQUEST FORM

Lot C7-C9, Conurbation 2, Cat Lai Industrial Zone, District 2, HCMC, VN

Tel: 84-28-37421604~6 - Fax: 84-28-37421603 - Email: [email protected]
ALL FIELDS WITH ASTERISK ** AS MANDATORY INFORMATION, MUST BE COMPLETED
(Same construction) fabric/PU/vinyl)
Yes No, final packaging is not
Final packaging
available
Yes

Assembly Instruction
included

No
State Age Grade Used for testing OR Age Grade determined by BVCPS Vietnam
D. TEST REQUEST: ( If no desired test request or checkbox is found, please specify at section E) **
PRODUCT (QUALITY) TEST: TRANSIT (PACKAGING) TEST:
Per protocol/standard: Per protocol:
Additional Product (Quality) test: please choose below: Per test method: please choose below:
US Lead in surface coating ( CPSIA – 16 CFR 1303 – Limit: 90 ISTA 1A ( for item £ 150Lbs)
ppm ) ISTA 1B ( for item > 150Lbs)
US Lead in substrate ( CPSIA – Limit: 100 ppm ) ISTA 1C/1D (All types of weight)
Canada Total lead content in surface coating (CCPSA / Surface coating ISTA 2A ( for item £ 150Lbs)
materials regulations) ISTA 2B ( for item > 150Lbs)
Illinois lead content in surface coating (40ppm) ISTA 2C ( for Case Goods) Atmospheric
Illinois lead content in substrate (40ppm ) Conditioning (Optional)
Phthalates content, please state name (Ex: BBP/ DBP…):
ISTA 3A ( for item £ 150Lbs) Atmospheric
Conditioning (Optional)
ISTA 3B Atmospheric Conditioning
(Optional)
Heavy metals in coating - ASTM F963 (US) ISTA 6-AMAZON
Heavy metals in substrate - ASTM F963 (US) NMFTA, Item 181
Canada Heavy metals content in surface coating (CCPSA / Toys ISTA6 FedEx-A U.S. Shipment ISTA6 FedEx-A
regulations) International shipment
EN 71-3:2019 ISTA6 FedEx-B U.S. Shipment ISTA6 FedEx-B
CA TB 117-2013, please fill out which section:___________ International shipment
Bursting strength - TAPPI T810
Edgewise Compressive Strength - TAPPI T839
Edgewise Compressive Strength - TAPPI T811
om-17
CPSIA testing to complete reasonable testing program for Third Party testing:
CPSIA Total Lead content in Surface Coating – 16 CFR 1303 (Limit: 90 ppm) (included use & abuse test with additional
charge $26/item for children product) Individual or Composite
CPSIA Total Lead content in Substrate (included use & abuse test with additional charge for children product) – Limit:
100 ppm Individual or Composite
CPSIA Phthalates content Individual or Composite (up to 3 like materials)
BBP/DBP/DEHP content
DNOP/DINP/ DIDP content
BBP/DBP/DEHP/DINP/DIBP/DPENP/DHEXP/DCHP (product manufactured/imported as of April 25, 2018)
BBP/DBP/DEHP/DINP/DIBP/DPENP/DHEXP/DCHP/DIDP/DNOP
Client’s DnHP content
EU MARKET (Please write clearly test standard/method with version , ex: BS EN 12520:2015)
Indoor furniture: Please select level for testing: Level 1 Level 2 Level 3
Level 4 Level 5
BV-Magnussen-CPSD-HL-TRFS-VN-TRF-V00 Page 2 of 6 SEP-2024
 Bureau Veritas Consumer Products Services Vietnam Ltd.
TEST REQUEST FORM

Lot C7-C9, Conurbation 2, Cat Lai Industrial Zone, District 2, HCMC, VN

Tel: 84-28-37421604~6 - Fax: 84-28-37421603 - Email: [email protected]
ALL FIELDS WITH ASTERISK ** AS MANDATORY INFORMATION, MUST BE COMPLETED
Outdoor furniture: Please select level for testing: Camping Level Domestic
Level Contract Level
Children furniture:

E. OTHER TESTS/INSTRUCTIONS, PLEASE WRITE HERE:

Test(s) Required/ Yêu cầu kiểm tra
MAGNUSSEN TEST REQUIREMENTS
Lead test
In coating In substrate (only required when there is no coating on submitted sample)

EMC test
(Chamber Moisture Content at 4%, Temperature at 38degree C, Relative Humidity at 18-20%).
Check every 3,7,10days

Stability tipping test ASTM F2057-23 (Modified at 65lbs)

Magnussen Havertys

Construction test for chair, bench, stool

Test for fabric, foam, leather, or other upholstered materials.

TB117 Frame retardant (15 substances)
PFAS (TOF for US market). If FAIL, Perform Main PFAS substances for States which have
specific regulation)

Transit test
1A/1B Rule 181 for Havertys

Yellowing test
ASTM-G154 cycle 1 -72hrs (Check every 24h)

TSCA Title VI for Composite wood/Laminated veneer

Other tests

 Please always copy Roxie at [email protected] for any samples tested for Magnussen even factory will pay
the for test.
 Logo in all reports (Effective from May.2024)

 Inform Roxie at [email protected] a verbal result if any sample FAILED before a report is released.

Note: As part of our ongoing security enhancements, Bureau Veritas Consumer Products Services has implemented a report
security solution to digitally sign test reports and include a unique security QR code. To offset the implementation and
ongoing maintenance costs of this solution, a nominal fee of USD 1 will be charged per test report issued. By signing below,
you acknowledge your understanding and agreement to the Report Security Fee outlined above.
BV-Magnussen-CPSD-HL-TRFS-VN-TRF-V00 Page 3 of 6 SEP-2024
 Bureau Veritas Consumer Products Services Vietnam Ltd.
TEST REQUEST FORM

Lot C7-C9, Conurbation 2, Cat Lai Industrial Zone, District 2, HCMC, VN

Tel: 84-28-37421604~6 - Fax: 84-28-37421603 - Email: [email protected]
ALL FIELDS WITH ASTERISK ** AS MANDATORY INFORMATION, MUST BE COMPLETED

Carton retention & repacking (20USD/carton will be charged; the original state of carton/packaging materials is not
guaranteed; BV is not responsible for damages due to testing or transportation)

SAMPLE RETURN Self-collect after testing Destroy after testing

Date: ________________ Authorized Signature and Chop: ________________

(Remark: 1. Carrier has responsibility to handling with care for this kind of sample return;
2. BV Vietnam does not repack as original as limited proper facility)

(All requested test(s) will be performed according to the test method(s)/ standards(s) appropriate to industrial practice
which is determined by the laboratory, unless specified.)

**Date: ___04/22/2024_____________ **Authorized Signature and Chop: ________________

BV-Magnussen-CPSD-HL-TRFS-VN-TRF-V00 Page 4 of 6 SEP-2024

 Bureau Veritas Consumer Products Services Vietnam Ltd.
TEST REQUEST FORM

Lot C7-C9, Conurbation 2, Cat Lai Industrial Zone, District 2, HCMC, VN

Tel: 84-28-37421604~6 - Fax: 84-28-37421603 - Email: [email protected]
ALL FIELDS WITH ASTERISK ** AS MANDATORY INFORMATION, MUST BE COMPLETED
ADDITIONAL INFORMATION FORM FOR CPC/ GCC
CPSIA applicable rules review and CPC/GCC under BVCPS CPC/GCC service scope - Request Form

Note: Only fill out below sections if GCC/CPC checkbox in page 1 is selected.

MANUFACTURER’S INFORMATION
(Required for Domestic Manufacturer’s)
Company Name:
Mailing Address:

Telephone No.:
IMPORTER’S INFORMATION
(Required for Imports)
Company Name:
Mailing Address:

Telephone No.:
PERSON MAINTAINING TEST RECORD INFORMATION
Contact Person:
Mailing Address:

Telephone No.:
Email Address
Date of Manufacturer:
(MM/YYYY)
Place of Manufacturer:
(City / Province / Country)

BV-Magnussen-CPSD-HL-TRFS-VN-TRF-V00 Page 5 of 6 SEP-2024

 Bureau Veritas Consumer Products Services Vietnam Ltd.
TEST REQUEST FORM

Lot C7-C9, Conurbation 2, Cat Lai Industrial Zone, District 2, HCMC, VN

Tel: 84-28-37421604~6 - Fax: 84-28-37421603 - Email: [email protected]
ALL FIELDS WITH ASTERISK ** AS MANDATORY INFORMATION, MUST BE COMPLETED

Condition of Service
This report is governed by, and incorporates by reference, the Conditions of Testing as posted at the date of issuance of this
report at http://www.bureauveritas.com/home/about-us/our-business/cps/about-us/terms-conditions/ and is intended for
your exclusive use. Any copying or replication of this report to or for any other person or entity, or use of our name or
trademark, is permitted only with our prior written permission. This report sets forth our findings solely with respect to the
test samples identified herein. The results set forth in this report are not indicative or representative of the quality or
characteristics of the lot from which a test sample was taken or any similar or identical product unless specifically and
expressly noted. Our report includes all of the tests requested by you and the results thereof based upon the information
that you provided to us. Measurement uncertainty is only provided upon request for accredited tests. Statements of
conformity are based on simple acceptance criteria without taking measurement uncertainty into account, unless
otherwise requested in writing. You have 60 days from date of issuance of this report to notify us of any material error or
omission caused by our negligence or if you require measurement uncertainty; provided, however, that such notice shall be
in writing and shall specifically address the issue you wish to raise. A failure to raise such issue within the prescribed time
shall constitute your unqualified acceptance of the completeness of this report, the tests conducted and the correctness of
the report contents

BV-Magnussen-CPSD-HL-TRFS-VN-TRF-V00 Page 6 of 6 SEP-2024