只供本中心使用 For Office Use Only
Application No. :Customer No. :香港標準及檢定中心THE HONG KONG STANDARDS AND TESTING CENTRE LTD
用戶室內設備驗證 申請表(申請表格號碼: EMD/LCB/F/019)
APPLICATION FOR CERTICATION OF CUSTOMER PERMISESEQUIPMENT (Form Number: EMD/LCB/F/019)

甲部
PART A

申請人(證書持有人)資料
PARTICULARS OF APPLICANT (CERTIFICATE HOLDER)

Received on :Committed on :Reviewed By :Date :(請參閱填寫表格須知第 1 項)
(See Guidance Notes 1)

1. 公司名稱:Company Name:﹝英文、請用正楷﹞ (In English BLOCK LETTERS)﹝中文、如適用﹞ ( In Chinese, if applicable)
2. 公司地址
Company Address:
3. 在貴公司負責這項申請人士的姓名，電話號碼、傳真號碼及電郵地址：
Give the name, telephone number, facsimile number and email address of the person in your company who is responsible for this application:
姓名 ﹝英文﹞Name ( In English ):電話號碼
Telephone No.:﹝中文、如適用﹞( In Chinese, if applicable)
傳真號碼
Fax No.:(先生)(Mr.)(女士)(Ms.)

電郵地址
Email Address:(若你想授權代理人代你申請驗證，請填寫下列資料。一份由申請人簽發委託代理人代為申請驗證的授權書必須連同申請表格一併遞交。
你並非必須委託任何人代你申請。)(Complete only if you wish to authorize an agent to apply for certification on your behalf. A letter of authorization from the Applicant authorizing
the agent to apply for certification on the Applicant's behalf must be enclosed with this application form. Authorization is NOT compulsory.)
4. 授權代理人的公司名稱:Company Name of Authorized Agent:公司地址Company Address:
聯絡人姓名 ﹝英文﹞Name of Contact Person ( In English ):電話號碼
Telephone No.:

EMD/LCB/F/019, Rev. H﹝中文、如適用﹞( In Chinese, if applicable)
傳真號碼
Fax No.:

電郵地址
Email Address:-1-(先生)(Mr.)(女士)(Ms.)

乙部PART B

製造商資料
PARTICULARS OF MANUFACTURER(請參閱填寫表格須知第 2-3 項)(See Guidance Notes 2-3)

1. 製造商名稱:Name of Manufacturer:
2. 製造商地址
Address of Manufacturer:
聯絡人姓名 ﹝英文﹞Name of Contact Person ( In English ):電話號碼
Telephone No.:丙部
PART C﹝中文、如適用﹞( In Chinese, if applicable)
傳真號碼
Fax No.:

電郵地址
Email Address:

用戶室內設備資料
DETAILS OF CUSTOMER PERMISES EQUIPMENT(請參閱填寫表格須知第 2-3 項)(See Guidance Notes 2-3)

1. 適合的 HKCA/HKTA 規格:
Applicable HKCA/HKTA Specification(s):2. 設備類別:Type of Equipment:
3. 牌子:
Brand Name:

5. 型號:
Model No.:

4. 商用名稱(如有)Trade Name (if any):

6. 製造年份:Year of Manufacture:

EMD/LCB/F/019, Rev. H-2-(先生)(Mr.)(女士)(Ms.)

丁部PART D

申請人聲明
DECLARATION OF APPLICANT

致: 香港標準及檢定中心
To: The Hong Kong Standards and Testing Centre Ltd
1.
本人/我們謹此聲明，本申請表填報的資料和夾附的文件均屬真實，完整及正確無誤。
I/We hereby declare that the information and document given in this application form is true, correct and complete.
2.
本人/我們謹此證實，所提交的樣本為本表格內所申報的設備。
I/We hereby confirmed that the submitted sample is representative of the equipment as stated in this application form.
3.
本人/我們謹此證實，提交的測試報告內所述的測試樣本，均是與正式生產時的設備相同並具代表性及沒有作出任何改動。
I/We hereby confirmed that the submitted test reports were for test conducted on a representative unmodified sample the same as the equipment to be
manufactured.
4.
本人/我們謹此證實，本設備及其有關資料已就法律要求得到所須的同意、准許和授權。本設備並不侵犯任何知識產權。
I/We hereby confirmed that all information disclosed to The Hong Kong Standards and Testing Centre Limited has proper consents, licenses orauthorities required by the laws and this equipment does not infringe upon any intellectual property rights.
5.
本人/我們同意遵守由香港標準及檢定中心制定並不時修訂之『本地認證機構對電訊設備和工業、科學及醫療設備進行驗證的計劃（本地認證機構計劃）』條例及附頁之『類型檢定/類型認可證書』一切條款，並承諾提供設備在驗證過程中所需的一切資料。
I/We hereby agree to abide by the "Regulations for Scheme on Certification of Telecommunication Equipment and Industrial, Scientific and Medical(ISM) Equipment by the Local Certification Bodies ("LCB Scheme") and the attached "Conditions on Issuing of Certificate of Type Approval / TypeAcceptance" as set forth and amended from time to time by the Hong Kong Standards and Testing Centre Limited, and supply any information neededfor evaluation of the equipment to be certified.
6.
本人/我們同意香港標準及檢定中心可向香港通訊事務管理局提供本次申請與測試和驗證有關的資料和文件，及在有需要時，容許通訊事務
管理局在其網頁內公佈。
I/We hereby agree The Hong Kong Standards and Testing Centre Ltd to transfer all information and materials of this application in relation to testing
and certification to OFCA and allowing OFCA to publish, where necessary, on its website.
7.
本人/我們同意香港標準及檢定中心可向第三方認可機構披露本次申請與測試和驗證有關的資料和文件，以作認可及審核用途。
I/We hereby agree The Hong Kong Standards and Testing Centre Ltd to disclose the testing and certification related documents and/or files to any
third-party accreditation bodies for audit or accreditation purposes.
8.
本人/我們同意凡因申請本次驗證所提供的設備、數據、陳述和資料而引致的任何糾紛、爭論或索賠等一切責任由本人/我們承擔。
I/We hereby agree to fully indemnify The Hong Kong Standards and Testing Centre Ltd of all damages or liabilities to any disputes, controversy, or
claims arising out of the equipment, data, statements, any other information provided for this application.
9.
本人/我們同意在獲通知鑑定結果的日期起計兩星期內，取回所提交的設備樣本。如果本人/我們未能在有關期限內取回，本人/我們同意香
港標準及檢定中心可決定以適當的方法處置該樣本。
I/We agree to collect the submitted sample within two weeks from the date of notification of the evaluation result. If I/we do not collect the submitted
sample within such period of time, I/We agree that the Centre may dispose of the submitted sample in whatever manner he considers appropriate.

授權代表簽署:
Signature of the Authorised Signatory:
簽署人姓名:
Signatory's full name:﹝請用正楷書寫﹞ (In BLOCK LETTERS)
職位:
Position Held:
申請人公司/機構印鑑Applicant's Company/Organization Chop

EMD/LCB/F/019, Rev. H

日期
Date:

-3-

申請人須知Notes to Applicants:
1.

請以正楷填妥所有有關部份，並須在不適用處填上「不適用」，在適當的內加上「」號。透過本表格提供個
人資料，屬自願性質。如在本表格提供的資料不正確或有不完整，香港標準及檢定中心(“本中心”)可能無法
辦理你的申請或將來已發的證書被撤銷。
Please complete all relevant parts in BLOCK letter. If a part is not applicable, please write “N/A”,  tick whereappropriate. The provision of personal data by means of this application form is voluntary. Incomplete or incorrect
information supplied on this form, THE HONG KONG STANDARDS AND TESTING CENTRE LTD. (the “Centre”)
may not be able to process your application or subsequent withdrawal of the certificate granted.

2.

每份申請表只可填寫一種設備的型號或類型編號。你所填寫的個人資料，將被本中心用以處理你的申請。
Use one application for only one model or type number of the equipment. The personal data provided by you will be usedby the Centre for processing your application made in this form.

3.

申請表必須蓋上申請人公司/機構印鑑或經由公司/機構之授權代表簽署方可生效。授權代表是獲申請人公司/機構授權可代表該公司/機構簽署具法律約束力文件的人員。
Application will only be effective with applicant's company / organisation stamp (where applicable) and/or signature of
the authorised signatory of the applicant company or organization. Authorised signatory is an officer or representative
vested with the powers to commit the authorizing organization to a binding agreement by signing it on its behalf.

4.

在評估你的申請時，或會向其他相關政府部門 / 機構披露你在本表格所提供的個人資料。
The personal data you provide by means of this form may be disclosed to other relevant government departments /agencies in connection with the assessment of your application.

5.

你有權要求查閱和更正你的個人資料。包括取得本申請表上所載個人資料的副本，惟索取這些資料時或須繳費。
You have a right of request for access and correction with respect to personal data. Your right of access includes the rightto obtain a copy of your personal data provided by this application form, though a charge may be levied on obtaining suchinformation.

6.

請參閱夾附的填寫須知；該指引提供有用的資料，協助閣下填寫本申請表。填妥的表格須連同所需的證明文件，送交本中心。如對本申請表有任何疑問，或對透過本申請表所收集的個人資料有問題，包括如何提出查閱
和改正個人資料的要求，請聯絡
電氣及電子產品部
香港標準及檢定中心
香港新界大埔工業邨大宏街 10 號
電話: +852 2666 1855
傳真: +852 2665 0848
電郵: hkep@stc.group
Please refer to the accompanying guidance notes which offer some useful information regarding this form. The completed
form, together with the required supporting documents, should be returned to the “Centre”. For further enquire about thisapplication form or concerning the personal data collected by means of this form, including the making of request foraccess and correction should be addressed to:Electrical Products Division
The Hong Kong Standards and Testing Centre Ltd
10 Dai Wang Street
Tai Po Industrial Estate
N.T., Hong Kong
Tel.: +852 2666 1855
Fax: +852 2803 0848
Email: hkep@stc.group

EMD/LCB/F/019, Rev. H-4-填寫表格須知
1. 申請人一般須為有關設備的製造商或其授權代表、或設備供應商。若申請人是測試代理商或顧問，則需提交一封由設備製造商的授權信件以表明該申請人是獲授權代表設備製造商提交驗證申請。
2. 丙部所填寫的牌子及型號須能用以清楚辨認正在申請驗證的設備。假如丙部所載的牌子及型號，與申請人所提交的有關證書或測試報告有出入，申請人須提供詳細的解釋及製造商的聲明，以證明正在申請驗證的設備， 與申請
人所提交的證書或測試報告的設備的電力及機械規格完全一致。
3. HKCA/HKTA 規 格 訂 明 用 戶 室 內 設 備 的 技 術 規 定 ， 有 關 詳 情 載 於 ：http://www.ofca.gov.hk/tc/industry_focus/telecommunications/standards/hkca/fixed_network_equipment_specifications/ind
ex.html 。基本上，很多種類的用戶室內設備均沒有強制驗證的規定，只要符合指定的 HKCA/HKTA 規格，便可在 本 地 市 場 出 售 。 請 參 閱 編 號 OFCA I 421 的 「 香 港 電 訊 設 備 鑑 定 及 驗 證 計 劃 」 資 料 便 覽 ：http://www.ofca.gov.hk/tc/industry_focus/telecommunications/standards/telecom/information_notes/index.html。
4. 如對測試報告的詮釋、進行測試的方法和設備製造商所提交的聲明的真確性有任何爭議，以本中心的決定為準。
5. 不完整、不充足或不適當的文件或會導致申請進度受阻甚至申請被拒。申請人因此應確保所提交的文件完整及準確。所有用以支持申請的文件，包括測試報告、證書等，均須以中文或英文撰寫。如證明文件是以其他語言撰寫，申請人須提供經認證的中文或英文譯本。這些證明文件宜以光碟或其他電子形式提交。
6. 其他額外資料可參閱編號 OFCA I 412 的「怎樣申請為連接本港公共電訊網絡的用戶室內設備驗證」資料便覽：http://www.ofca.gov.hk/tc/industry_focus/telecommunications/standards/telecom/information_notes/index.html 。 申 請 費用須在遞交申請時繳付。
7. 可以支票、銀行本票或銀 行 匯 票 方式繳 付申請費 。劃 線 支 票 、 銀 行 本 票 或 銀 行 匯 票 須 註 明 支 付 予 「 香港標準
及檢定中心有限公司」 。由 海 外 銀 行 發 出 的 銀 行 匯 票 所 填 款 額 須 包 括 本 地 銀 行 收 取 的 費 用 。 請 於 支 票 、 銀
行 本 票 或 銀 行 匯 票背 面 寫上 申 請 人 的姓名及申請檢定的 設 備 型 號。 申 請 人 應於 本 中 心 所 發 出 的發 票 日期 或
由本中心以書面同意的特定日期內準時支付有關該申請的所有費用，否則該申請人需要支付本中心 發票
日 期 起 計至 實 際付 款 日期的 利 息 （以 每月 3 厘計） 。 該 申請 人 亦須 支 付本公 司 用 於追 討 該筆 欠 款的所 有
費 用 ， 包括 法 律費 用 。
8. 如申請獲得批准，本中心會保留申請人提交的所有技術文件。如申請不獲批准，申請人將獲通知有關結果。在接獲本中心通知前，無需送交設備樣本。
- 完 -EMD/LCB/F/019, Rev. H-5-

Guidance Notes for Completion of Form
1.

Applicants are normally the manufacturers of the equipment, or its authorised representatives, or equipment suppliers. In
case the applicant is a testing agency or consultant, an authorisation letter from the equipment manufacturer indicating
the applicant is acted on behalf of the equipment manufacturer in applying for certification should be submitted.

2.

Brand name and model number given in Part C should be able to uniquely identify the equipment under application. In
case that the brand name and model number as given in Part C are different from those in the submitted certificate or test
report, the applicant should provide detailed explanation and a manufacturer's declaration to confirm that the equipment
under application is electrical1y and mechanically identical to the one covered by the submitted certificate or test report.

3.

The technical requirements for customer premises equipment are prescribed in the HKCA/HKTA specifications, whicharepublishedindetailsat
http://www.ofca.gov.hk/en/industry_focus/telecommunications/standards/hkca/fixed_network_equipment_specifications/index.html. Basically, certification is not a mandatory requirement for many types of customer premises equipment,
which can be placed in the local market without certification provided that they comply with the prescribed
HKCA/HKTA specifications. Applicant is advised to refer to information note OFCA I 421 “Hong Kong
Telecommunications
Equipment
Evaluation
andCertification(HKTEC)
Scheme”
at
http://www.ofca.gov.hk/en/industry_focus/telecommunications/standards/telecom/information_notes/index.html
fordetails of certification schemes in Hong Kong.

4.

In cases of doubt relating to the interpretation of the test report, the method of carrying out the tests and the validity of thestatements made by the manufacturers of the equipment, the decision of the Centre should be final.

5.

Incomplete, inadequate or improper documentation may cause delay or reject of an application. The applicant isrequested to pay attention to ensure the completeness and accuracy of documentation. All supporting documents,
including the test report, certificate etc., should be in either Chinese or English language. For those supporting documents
written in other language, applicants should provide a certified copy of the translation in Chinese or English. Copies ofthese supporting documents in CD format or other electronic formats are preferred.

6.

For other additional information, please refer to an information note OFCA I412 “How to Apply for Certification ofCustomer Premises Equipment to be Connected to the Public Telecommunications Network in Hong Kong” at
http://www.ofca.gov.hk/en/industry_focus/telecommunications/standards/telecom/information_notes/index.html.
Theapplication fee is payable at the time of submitting the application.

7.

Payment by cheque, cashier order or bank draft is acceptable. Crossed cheque, cashier order or bank draft should be madepayable to "The Hong Kong Standards and Testing Centre Ltd.". The bank draft issued by overseas bank should
cover the charges of our local bank. The name of applicant and equipment model under application should be given at
the back of the cheque, cashier order or bank draft. The Applicant shall punctually pay on the date of invoice or within suchother period agreed in writing by the Centre all charges rendered by the Centre or interest will become due at the rate of three per centper month from the date of invoice until actual payment. The Applicant is also responsible for settling all the Centre's costs ofcollecting the charges owed, including legal fees.

8.

For successful applications, all the technical documents submitted will be retained by the Centre. For unsuccessful
applications, applicants will be informed of the evaluation results. No equipment sample is to be sent until advice fromthe Centre.
- End -

EMD/LCB/F/019, Rev. H-6-

類型檢定/類型認可證書之條款
1.

證書持有人同意遵守由香港標準及檢定中心制定之『本地認證機構對電訊設備和工業、科學及醫療設備進行驗證的計劃（本地認證機構計劃）』條例。

2.

如設備的牌子名稱/型號或其他資料有任何改動，須事先取得香港標準及檢定中心的批准。

3.

如事先未取得香港標準及檢定中心的批准，不得對設備作出電氣或機械改動。

4.

香港標準及檢定中心有限公司保留要求提交有關設備額外樣本的權力，以便對在市面上出售的有關設備與通訊
事務管理局所定的規格作測試比較。

5.

如已推出市場的設備不符合香港通訊事務管理局訂明的技術規格或證書持有人違反證書的任何條件，證書可被撤銷。

6.

如經驗證設備不符合訂明的技術或安全要求，證書持有人須按照香港標準及檢定中心或香港通訊事務管理局的規定，採取補救措施或回收已推出香港市場的經驗證設備。

7.

對於規管在香港使用或出售的電訊設備和蓄意發出射頻能量的工業、科學及醫療設備的技術法規，通訊事務管
理局保留根據法律解釋，實施和執行的一切權力。

8.

證書持有人允許通訊事務管理局辦公室在其網站公布有關的技術資料。

9.

如有關設備是一件用戶室內設備，並在連接香港公共電訊網絡時產生問題，證書可被撤銷，而所有已推出市場
的設備可能需要回收。

10.

已獲發證的無線電訊設備可以貼上 HKCA3211 – 有關電訊設備標籤的標準化指引所規定的式樣的標籤，以作識
別。 ( 註 : 香港標準及檢定中心有限公司並不擁有該標籤的所有權，亦沒有權力解釋此 HKCA 指南內的規定。
為避免疑義，上述標籤是由通訊事務管理局規定，標籤的要求並非在 ISO/IEC 17065 認可的範圍內 )11.

驗證制度為 ISO/IEC 17067:2013 之第 1a 模式。驗證是按照『本地認證機構對電訊設備和工業、科學及醫療設備
進行驗證的計劃（本地認證機構計劃）』進行。

EMD/LCB/F/019, Rev. H-7-

Conditions of Issuance of Certificate of Type Approval / Type Acceptance1.

The certificate holder is agreed to abide by the Regulations for Scheme on Certification of Telecommunication
Equipment and Industrial, Scientific and Medical (ISM) Equipment by the Local Certification Bodies (“LCB Scheme”)
as set forth and amended from time to time by The Hong Kong Standards and Testing Centre Ltd.

2.

Prior approval from The Hong Kong Standards and Testing Centre Ltd. is required for any alteration in Model No. /Brand Name or other particulars for the equipment.

3.

No electrical or mechanical change shall be made to the equipment without prior approval from The Hong Kong
Standards and Testing Centre Ltd.

4.

The Hong Kong Standards and Testing Centre Ltd. reserves the right to call for additional samples of the equipment
marketed for testing against the Communications Authority’s specifications.

5.

The certificate may be withdrawn if the equipment marketed is found not meeting the technical specification(s)prescribed by the Communications Authority of Hong Kong or any of the conditions on the certificate is breached.

6.

The certificate holder shall perform remedial actions or recall the certified equipment marketed in Hong Kong as may berequired by The Hong Kong Standards and Testing Centre Ltd. or the Communications Authority of Hong Kong if they
are found not meeting the prescribed technical or safety requirements.

7.

The Communications Authority retains all authority under the law to interpret, implement and enforce the relevant
technical regulations governing telecommunications equipment, as well as industrial, scientific and medical equipment
emitting radio frequency energy intentionally, which is for use or sale in Hong Kong.

8.

The grantee of the certificate allows the Office of the Communications Authority to publish the relevant technicalinformation on its website.

9.

The certificate may be withdrawn and all the marketed equipment may be recalled if the equipment is a customer
premises equipment and generates connection problems in the Hong Kong public telecommunications network.

10.

The equipment certified can be suitably identified by a label in a format stipulated in the HKCA3211 – Standardisation
Guide for Labeling of Telecommunications Equipment. (Note: The Hong Kong Standards and Testing Centre Ltd. does
not own the proprietary right of the label nor do we have the authority to interpret the requirements in that HKCA Guide.
For avoidance of doubt, the aforesaid label is prescribed by the Communication Authority, the labelling requirement is
outside the scope of ISO/IEC 17065 accreditation).

11.

Product certification system is Type 1a as defined in ISO/IEC 17067:2013. Certification is based on the “Scheme on
Certification of Telecommunication Equipment and Industrial, Scientific and Medical (ISM) Equipment by the Local
Certification Body (LCB Scheme)”.

EMD/LCB/F/019, Rev. H-8-