Item 1: Applicant's complete, legal business name:
|
| Item 2: Applicant's mail
address: |
Line 1:
Line 2:
P.O. Box:
City:
Country: (if foreign address)
|
State:
Zip/Postal Code:
|
| |
| Item 3: FCC ID:
Grantee Code:
Equipment Product Code (14
characters max):
|
| |
| Item 4: Person at the
applicant's address to receive grant or for contact: |
First Name:
Last Name:
Line 1:
Line 2:
Country (if foreign address):
Telephone:
Ext:
Title:
Email:
|
Mail Stop:
P.O. Box:
City:
State:
Zip/Postal Code:
|
|
| Item 5: Instead of
Applicant, TCB is authorized to mail original Grant to: |
Firm Name:
First Name:
Title:
|
Last Name:
Mail Stop:
|
| |
| Item
6: Technical Contact: |
First Name:
Last Name:
Line 1:
Line 2:
Country (if foreign address):
Telephone:
Ext:
Title:
Email:
|
Mail Stop:
P.O. Box:
City:
State:
Zip/Postal Code:
|
| |
| Item 7: Non-Technical Contact: |
First Name:
Last Name:
Line 1:
Line 2:
Country (if foreign address):
Telephone:
Ext:
Title:
Email:
|
Mail Stop:
P.O. Box:
City:
State:
Zip/Postal Code:
|
| |
| Item 8: Does this
application include a request for confidentiality for any portion(s) of
the data contained in this application pursuant to 47 CFR 0.459 of the
Commission Rules? Yes No
|
Item 9: Does the applicant
request that the Commission defer grant of this application pursuant to 47
CFR 0.457(d)(l)(ii)? Yes No
If so, specify date when grant may issued: (MM/DD/YY):
|
Item 10: Equipment Code:
Equipment will be operated
under FCC Rule Part(s):
Description of Product as it is Marketed:
|
Item 11: Application is
for
Original Equipment
Change in identification of
presently authorized equipment | Original FCC ID:
Grant Date: (MM/DD/YY):
Class II permissive change or
modification of presently authorized equipment |
| Item 12: Equipment
Specifications: |
|
| Frequency range
in MHZ |
Rated RF Power
output in watts |
Frequency tolerance |
Emission
designator |
Microprocessor
Model number |
|
|
%
%
%
%
%
|
|
|
Item
13: Is the equipment in this application
(a) a composite device subject to an additional equipment
authorization?
(b) part of a system that operates with, or is marketed with, another
device that requires an equipment authorization?
If either of the above questions is answered "Yes" complete section
13(c).
(c) The related application:
was filed at same time as
this application under the FCC ID listed to the right.
has been granted under the
FCC ID listed to the right.
is in the process of being
filed under the FCC ID listed to the right.
is pending with the FCC
under the FCC ID listed to the right.
|
Yes
No
Yes
No
FCC ID: |
Item 14: Name of the test
firm and contact person on the file with the FCC, if different from
applicant or contact person:
Firm Name:
First Name:
Last Name:
Telephone:
Ext:
Fax No.:
Email:
|
Item 15: SECTION 5031
(ANTI-DRUG ABUSE) CERTIFICATION:
The applicant must certify that neither the applicant nor any party to the
application is subject to a denial of Federal benefits, that include FCC
benefits, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, 21
U.S.C. 862 because of a conviction for possession or distribution of a
controlled substance. See 47 CFR 1.2002(b) for the definition of a
"party" for these purposes.Does the applicant or authorized agent so
certify?
Yes
No
|
| Item 16: APPLICATION/AGENT
CERTIFICATION: I certify that I am authorized to sign this application.
All of the statements herein and the exhibits attached hereto, are true
and correct to the best of my knowledge and belief. In accepting a
Grant of Equipment Authorization issued by the FCC as a result of the
representations made in this application, the applicant is responsible for
(1) labeling the equipment with the exact FCC ID specified in this
application, (2) compliance statement labeling pursuant to the applicable
rules, and (3) compliance of the equipment with the applicable technical
rules. If the applicant is not the actual manufacturer of the
continue to comply with the FCC's technical requirements.
Authorizing an agent to sign this application, is done soley at
applicant's discretion; however, the applicant remains responsible for all
statements in this application.
If an agent has signed this application on behalf of the applicant, a
written letter authorization which includes information to enable the
agent to respond to the above section 5301 (Anti-Drug Abuse) Certification
statement has been provided by the applicant. It is understood that
the letter of authorization must be submitted to the FCC upon request and
that the FCC reserves the right to contact the applicant directly at any
time.
|
Name
of Authorized Person Filing:
|
Title
of Authorized Person:
|
Complete
items below if an agent signs this application:
Firm Name:
Telephone:
Middle Initial:
First Name:
Last Name:
Line 1:
Line 2:
Country (if foreign address):
Email:
|
Ext:
Fax No.:
P.O. Box:
City:
State:
Zip/Postal Code:
|