Timco Engineering, Inc.
TCB Application Form 731
Rev 22 June 2004
For Timco Use Only
Job Number 1147TC5
Scope A-4
Date Filed 06/08/05
Conf. #
Grant Note
TC692258
PWER LISTED &
CONDUCTED + “F”
Shaded areas are REQUIRED
Item 1. Applicant’s complete, legal business name:
Surecom Technology Corp.
Applicant’s FCC Registration Number (FRN): 0010870236
Item 2. Applicant’s mailing address: fill in fields, as appropriate
Line 1: 6F, No. 125, Sec. 2, Datung Rd., Shijr City,
Line 2 :
P.O. Box:
City: Taipei
State: Country (if foreign address):
Taiwan
Zip/Postal Code:
221
Item 3. Applicant Contact Person:
First Name:
Title:
E-mail:
Paul [email protected]
Item 4. FCC ID consisting of:
Grantee Code:
MP3
Last Name: Shih
Telephone: 886-2-86926200
Fax No.: 886-2-86926203
Equipment Product Code (14 characters maximum):
-9101G-0504 include “dashes” (-) where appropriate
Item 5. Application Contact: All questions regarding the application will be directed to this contact. The Original
Grant and Invoice will be sent to this contact.
Firm Name:
Spectrum Research & Testing Lab.
Telephone:
+886-3-4987684
Ext: Fax: No.:
+886-3-4988194
First Name: Johnson Middle Initial:
Address Line 1: No. 101-10, Ling 8, Shan-Tong Li, P.O. Box
Last Name:
:
Ho
Address Line 2:
Country (if foreign address): Taiwan, R.O.C.
City: Chung-Li, Taoyuan
Zip/Postal Code:
State:
320
E-mail: [email protected]
Item 6.
Test Firm Used to Take Measurements:
Telephone:+886-3-4987684 Fax:+886-3-4988194
Firm Name:
Spectrum Research & Testing Lab.
First Name: Johnson
Telephone:
+886-3-4987684
Middle Initial:
Ext.: Fax No.:
+886-3-4988194
Last Name: Ho
Address Line 1: No. 101-10, Ling 8, Shan-Tong Li,
Address Line 2: City: Chung-Li, Taoyuan
P.O. Box:
State:
Country (if foreign address): Taiwan, R.O.C.
E-mail: [email protected]
Zip/Postal Code:
FCC Registered Test Site Number.
Required for Part 15 and 18 applications.
320
Item 7 .
* Does this application include a request for SHORT-TERM confidentiality for any portion(s) of the data contained in this application pursuant to FCC DA 04-1705 dated 6/15/2004?
SHORT-TERM request:
Yes No
* 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?
PERMANENT request:
Yes
Item 8. * Is this application for modular approval? Yes No
If yes, please submit a cover letter addressing the modular approval requirements of DA 00-1407.
No
Item 9. * Is this application for software defined radio authorization? Yes No
Item 10. Equipment Class: 3-digits required Description of Product as it is marketed:
DTS 802.11g 54M Wireless LAN Media Adapter
Item 11. *Application is for:
Original Equipment
Change in identification of presently authorized equipment:
Original FCC ID Grant Date (MM/DD/YYYY)
Class II permissive change or modification of presently authorized equipment
Class III permissive change to software defined radio
Note: this may only be filed for applications pertaining to Software Defined Radio
Item 12. 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 12 (c).
Yes
Yes
No
No
(c) The related application:
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
FCC ID
Item 13. * Equipment will be operated under
FCC Rule Part(s):
Item 14. EQUIPMENT SPECIFICATIONS: Where applicable
Frequency range in MHz Rated RF Frequency tolerance
Low Freq High Freq power output
IN
WATTS
%, Hz, ppm
Emission
Designator
(See
47 CFR 2.201 and
2.202)
Microprocessor model number
2412 2462 0.005
Read each certification carefully before answering and signing this application
WILLFUL FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S.
CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT
(U.S. CODE, TITLE 47, SECTION 312 (a) (1)), AND/OR FORFEITURE (U.S. TITLE 47, SECTION 503).
(Continued on Next Page)
Item 15. APPLICANT/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 TCB, under the authority of 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 equipment, appropriate arrangements have been made with the manufacturer to ensure that production units of this equipment will continue to comply with the FCC’s technical requirements.
Authorizing an agent to sign this application is done solely at the 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 of 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.
*Signature of Authorized Applicant: Johnson Ho
Title of Authorized Signature: Director
NOTE: An asterisk ‘*’ preceding a field indicates it must be completed.
Instructions for completing the Timco Engineering, Inc.
TCB Application Form 731
All Shaded areas are required
Item 1, Item 2 and Item 3:
Please complete these sections with the APPLICANT’S contact information. This information will be verified against the information listed in the FCC’s database. Changes in Applicant contact information must be handled separately with the FCC. Contact us if changes to the Applicant’s information is necessary.
Item 4:
Please enter the FCC ID of the device. The FCC ID consists of the 3-digit Grantee Code and an Equipment
Product Code. The Equipment Product Code may consist of up to 14 characters and may contain “dashes” (-).
Please remember to use dashes when appropriate.
Item 5:
Application Contact - This is Timco’s customer. Only one contact is acceptable : the organization that submits the application. All correspondence regarding the application will be directed to this contact. When issued, the original
Grant and Invoice will be sent to this contact. This contact may not always be the test lab that performed the testing of the device. This contact may be a third-party agent or the Applicant itself. Please complete all areas.
Item 6:
Please indicate the name and location of the Test Laboratory where the testing took place. Please also identify the
Test Lab’s contact person and their contact information. For Part 15 and Part 18 applications please record the
FCC registered test site number.
Item 7:
Please indicate if a request for confidentiality of certain exhibits is requested with this application. You now can choose between short-term confidentiality or permanent confidentiality. Short-term confidentiality is described in
FCC DA 04-1705 dated 6/15/04. A separate cover letter exhibit must be submitted with the application explaining either request for confidentiality. This cover letter must refer to the correct FCC Rules that govern confidentiality, must indicate which exhibits confidentiality is requested for and must provide adequate reason for the request.
Additional fees apply.
Item 8:
Please indicate if the application if for modular approval. If yes, a separate cover letter must be submitted addressing the modular approval requirements of FCC DA 00-1407.
Item 9:
Please indicate if the application is for authorization of a software-defined radio.
Item 10:
Please provide the 3-digit Equipment Class. Examples of Equipment Classifications include “DXX” for Part 15 Low
Power Communication Device Transmitter and “8CC” for Part 18 Consumer Device (different Equipment
Classifications may apply for your device). Please provide a brief description of the device. The description that you enter here will appear on the final Grant of Equipment Authorization.
Item 11:
Please indicate what type of application is being submitted. With applications for a Change in ID of Previously
Authorized Equipment or a Class II Change, a separate cover letter exhibit explaining the details of the change must accompany the application.
Item 12:
Please indicate if the equipment in this application is a composite device or part of a system. Complete Item 12c only if you check “Yes” in Items 12a or 12b.
Item 13:
Please indicate the FCC Rule Part(s) that the equipment will be operated under.
Item 14:
Please complete the appropriate sections for the Equipment Specifications.
Item 15:
Please affix the signature and Title of the authorized Applicant.
