記入例

UL – FCC TCB PROGRAM
Application for FCC Certification – Form 731

SECTION I - ALL ITEMS IN THIS SECTION MUST BE COMPLETED
1. Applicant’s complete, legal business name
UL Japan, Inc.

該当情報を記載

Check here if this is a change inname and/or address not previously
reported

1A. Applicant’s Federal Registration Number (FRN)
1234567890
2. Applicant’s mailing address (Line 1)
4383-326 Asama-cho
Applicant’s mailing address (Line 2) (if required)
CityIse-shi
State or Country (if foreign address)

ZIP/Postal CodeMie-ken, JAPAN516-0021

3. FCC ID:(a) Grantee CodeXXX(b) Equipment Product Code(14 characters maximum,) show zeros as ø)
YYYY

4. Name, Title and Mail Stop, if any, of person at the applicant’s address to receive grant, or for contact:
UL Hanako
グランティ登録者と異なる場合、それを委任するレターが必要
5. (a) Telephone No. (Area/Country/City Code, No. and Ext.)
81-596-24-8116(b) FAX No. (Area/Country/City Code and No.)81-596-24-8124(c) Internet e-mail address: UL.Hanako@・・・・

SECTION II – CONTACT INFORMATION
1.(a) Instead of Applicant, original Grant shall be mailed to:Firm Name,UL Japan, Inc.
Number, street,4383-326 Asama-cho
City,Ise-shi
State/Country,Mie-ken, JAPAN
ZIP/Postal Code516-0021

担当者より詳細を連絡致します(b) Name, Title and Mail Stop, if any, of person at above address to receive Grant: Taro Tanaka
2.(a) Technical contact:
Firm Name,UL Japan, Inc.
First name
Jiro
Last name
TanakaNumber, street,4383-326 Asama-cho
City,Ise-shi
State/CountryMie-ken, JAPAN
ZIP/Postal code
516-0021(d) Internet e-mail address:Jiro.Tanaka＠・・・・(e) Non-Technical contact:
Firm Name,UL Japan, Inc.
First name
JiroLast name
TanakaNumber, street,4383-326 Asama-choCity,Ise-shi
State/CountryMie-ken, JAPAN
ZIP/Postal code
516-0021(h) Internet e-mail address: Taro.Tanaka＠・・・・(b) Telephone No. (Area/Country/City code, No. and Ext.)
81-596-24-8116(c) FAX No. (Area/Country/City code, and No.)81-596-24-8124(f) Telephone No. (Area/Country/City code, No. and Ext.)
81-596-24-8116(g) FAX No. (Area/Country/City code, and No.)81-596-24-8095

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該当箇所をチェック＆記載

Yes の場合、レター提出

SECTION III –EQUIPMENT AUTHORIZATION SUMMARY
1(a). Confidentiality Does this application include a request for confidentiality for a portion(s) of the data contained in this application
Yes
Nopursuant to 47 CFR 0.459 of the Commission's Rules?
1(b). Short Term Confidentiality Does the application include a request for short term confidentiality for a portion(s) of the datacontained in this application pursuant to short term confidentiality requirements of the Commission’s Rules?
YesNo
Yes の場合、別途料金必要
45-day90-day135-day
180-day
Other (-day)
If yes,2.

Is there a KDB inquiry associated with this application?
If yes, enter the KDB number:

3.

Modular Equipment

N/AYesSingle modular approval

No

Single limited modular approval

4. Defer Authorization Does the applicant desire to defer the grant of this application pursuant to 47 CFR 0.457(d)(ii)?
Yes
No If Yes, indicate the requested date the authorization is to become effective: __5.(a) Equipment Code and description:
Digital Transmission SystemDTS(b) Equipment will be operated under FCC Rule Part(s):15C

参照： https://apps.fcc.gov/oetcf/report_detail.cfm?report_url=/oetcf/eas/reports/EquipmentRulesList.cfm

5.(c) Description of product as it is marketed: (Note: this text will appear below the equipment class on the grant)
Digital camera
6. Application is for (Check one box only)
1. Originalequipment

2. Change in identification of presently authorized equipment

Original FCC ID

3. Class II permissive change ormodification of presently
authorized equipment

Grant date

7.Equipment Specifications:(a) Frequency rangein MHz(b) Rated RF power output
in watts (applicable only
when rule section provides
limits in terms of power)(c) Frequency tolerance%, Hz, ppm (Licenseddevices only)(d) Emission designator(See 47 CFR §2.201 and § 2.202)(Licensed devices only)(e) Microprocessor
model
number (Licenseddevices only)

2402-2480MHｚ

0.001W---(c)、(d)、(e)は A1、A4 の場合、記載不要利用帯域を記載。
規格の帯域記載は不可

8. Is the equipment in this application:(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?
9. If either of 8 (a) and/or (b) is answered “yes”, complete the following:
The related application:
has been granted under the FCC ID
listed below

is in the process of being filed underthe FCC ID listed below

YesYesNoNo

is pending with the FCC under theFCC ID listed below

FCC ID
10. (a) Name of test firm on file with the FCC, if different from applicant or contact person:(b)

Contact person:
Number, street,
City,
State/Country
ZIP/Postal code(c) Telephone No. (Area/Country/City code, No. and Ext.)(d) FAX No. (Area/Country/City code, and No.)(e) Internet e-mail address:

2/3SECTION IV - 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. CODE, TITLE 47, SECTION 503).
1. SECTION 5301 (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, thatinclude FCC benefits, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, 21 U.S.C. §862 because of a conviction forpossession or distribution of a controlled substance. See 47 CFR 1.2002(b) for the definition of a “party” for these purposes.
Yes
No
Does the applicant or authorized agent so certify?
2.(a) 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 andcorrect to the best of my knowledge and belief. If this application was previously submitted to the FCC or any otherTelecommunication Certification Body for FCC Certification, we agree to provide UL Japan with the complete details of the previousapplication. In accepting a Grant of Equipment Authorization issued by the FCC under the UL Japan TCB Program as a result of therepresentations 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 theapplicable 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 technicalrequirements.
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 toenable the agent to respond to the above Section 5301 (Anti-Drug Abuse) Certification statement has been provided by theapplicant. 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.
担当者より詳細を連絡致します

June 24, 2010
Date (Month, Day, Year)

Original written signature of authorized signer
Taro ULManager
Title of authorized signer

Typed/printed name of authorized signer
Complete items below if an agent signs the application,(b)Firm NameUL Japan, Inc.
First name
Taro
Last name
UL
Mailing address:
Number, street,4383-326 Asama-cho,City,
Ise-shi,State/CountryMie-ken, JAPAN
ZIP/Postal code
516-0021(e) Internet e-mail address: UL Taro@・・・・(c) Telephone No. (Area/Country/City code, No. and Ext.)
81-596-24-8116(d) FAX No. (Area/Country/City code, and No.)81-596-24-8095

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